- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,320.44 / $2,320.44 / $2,320.44
| Professional | | $2,320.44 | $2,320.44 | $2,320.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,176.00 / $5,011.00 / $7,314.00
| Professional | | $4,176.00 | $5,011.00 | $7,314.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,259.88 / $3,788.13 / $5,540.75
| Professional | | $3,259.88 | $3,788.13 | $5,540.75 |
- 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
- $3,629.45 / $5,283.28 / $8,578.68
| Professional | | $3,629.45 | $5,283.28 | $8,578.68 |