- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.41 / $2,029.41 / $2,029.41
| Professional | | $2,029.41 | $2,029.41 | $2,029.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,656.00 / $4,387.00 / $6,402.00
| Professional | | $3,656.00 | $4,387.00 | $6,402.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,864.83 / $3,319.92 / $4,889.63
| Professional | | $2,864.83 | $3,319.92 | $4,889.63 |
- 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
- $3,199.35 / $5,206.59 / $8,178.72
| Professional | | $3,199.35 | $5,206.59 | $8,178.72 |