- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.16 / $2,139.16 / $2,139.16
| Professional | | $2,139.16 | $2,139.16 | $2,139.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,804.00 / $4,565.00 / $6,661.00
| Professional | | $3,804.00 | $4,565.00 | $6,661.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,684.21 / $3,532.70 / $5,012.97
| Professional | | $2,684.21 | $3,532.70 | $5,012.97 |
- 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
- $3,047.55 / $4,685.82 / $8,355.60
| Professional | | $3,047.55 | $4,685.82 | $8,355.60 |