- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,160.58 / $2,160.58 / $2,160.58
| Professional | | $2,160.58 | $2,160.58 | $2,160.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,942.00 / $5,573.00 / $6,688.00
| Professional | | $4,942.00 | $5,573.00 | $6,688.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,965.59 / $3,037.63 / $5,164.42
| Professional | | $2,965.59 | $3,037.63 | $5,164.42 |
- 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
- $3,301.10 / $7,056.13 / $8,610.35
| Professional | | $3,301.10 | $7,056.13 | $8,610.35 |