- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.27 / $2,043.27 / $2,043.27
| Professional | | $2,043.27 | $2,043.27 | $2,043.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,654.00 / $4,385.00 / $6,400.00
| Professional | | $3,654.00 | $4,385.00 | $6,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,662.09 / $3,386.50 / $4,766.45
| Professional | | $2,662.09 | $3,386.50 | $4,766.45 |
- 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
- $3,007.95 / $5,075.45 / $8,139.13
| Professional | | $3,007.95 | $5,075.45 | $8,139.13 |