- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,372.19 / $2,372.19 / $2,372.19
| Professional | | $2,372.19 | $2,372.19 | $2,372.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,272.00 / $5,126.00 / $7,482.00
| Professional | | $4,272.00 | $5,126.00 | $7,482.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,294.51 / $3,878.44 / $5,657.68
| Professional | | $3,294.51 | $3,878.44 | $5,657.68 |
- 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
- $3,671.79 / $6,027.46 / $9,488.15
| Professional | | $3,671.79 | $6,027.46 | $9,488.15 |