- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,003.55 / $2,003.55 / $2,003.55
| Professional | | $2,003.55 | $2,003.55 | $2,003.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,582.00 / $5,166.00 / $6,199.00
| Professional | | $4,582.00 | $5,166.00 | $6,199.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,631.22 / $2,646.76 / $5,067.60
| Professional | | $2,631.22 | $2,646.76 | $5,067.60 |
- 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
- $2,454.56 / $4,789.10 / $8,438.74
| Professional | | $2,454.56 | $4,789.10 | $8,438.74 |