- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.53 / $1,563.53 / $1,563.53
| Professional | | $1,563.53 | $1,563.53 | $1,563.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,201.00 / $3,841.00 / $6,182.00
| Professional | | $3,201.00 | $3,841.00 | $6,182.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,009.14 / $2,591.52 / $3,709.60
| Professional | | $2,009.14 | $2,591.52 | $3,709.60 |
- 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
- $2,253.90 / $4,507.79 / $6,118.19
| Professional | | $2,253.90 | $4,507.79 | $6,118.19 |