- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,084.56 / $2,084.56 / $2,084.56
| Professional | | $2,084.56 | $2,084.56 | $2,084.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,706.00 / $4,447.00 / $6,491.00
| Professional | | $3,706.00 | $4,447.00 | $6,491.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,619.44 / $3,442.19 / $4,871.78
| Professional | | $2,619.44 | $3,442.19 | $4,871.78 |
- 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
- $2,974.96 / $5,056.35 / $8,147.04
| Professional | | $2,974.96 | $5,056.35 | $8,147.04 |