- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,302.52 / $2,302.52 / $2,302.52
| Professional | | $2,302.52 | $2,302.52 | $2,302.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,249.00 / $5,919.00 / $7,103.00
| Professional | | $5,249.00 | $5,919.00 | $7,103.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,278.20 / $3,282.33 / $5,503.25
| Professional | | $3,278.20 | $3,282.33 | $5,503.25 |
- 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
- $3,659.14 / $7,558.45 / $9,402.37
| Professional | | $3,659.14 | $7,558.45 | $9,402.37 |