- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,145.16 / $2,145.16 / $2,145.16
| Professional | | $2,145.16 | $2,145.16 | $2,145.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,909.00 / $5,535.00 / $6,642.00
| Professional | | $4,909.00 | $5,535.00 | $6,642.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,002.24 / $3,017.30 / $5,129.37
| Professional | | $3,002.24 | $3,017.30 | $5,129.37 |
- 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
- $3,347.84 / $6,695.69 / $8,632.79
| Professional | | $3,347.84 | $6,695.69 | $8,632.79 |