- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,991.34 / $2,991.34 / $2,991.34
| Professional | | $2,991.34 | $2,991.34 | $2,991.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,327.00 / $6,392.00 / $9,330.00
| Professional | | $5,327.00 | $6,392.00 | $9,330.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,843.13 / $4,939.47 / $7,119.61
| Professional | | $3,843.13 | $4,939.47 | $7,119.61 |
- 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
- $4,345.00 / $7,345.49 / $11,796.84
| Professional | | $4,345.00 | $7,345.49 | $11,796.84 |