- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,649.80 / $1,649.80 / $1,649.80
| Professional | | $1,649.80 | $1,649.80 | $1,649.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,832.00 / $4,598.00 / $7,402.00
| Professional | | $3,832.00 | $4,598.00 | $7,402.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,379.13 / $3,102.81 / $4,399.92
| Professional | | $2,379.13 | $3,102.81 | $4,399.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,668.59 / $4,535.10 / $7,282.42
| Professional | | $2,668.59 | $4,535.10 | $7,282.42 |