- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.52 / $2,080.52 / $2,080.52
| Professional | | $2,080.52 | $2,080.52 | $2,080.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,757.00 / $5,364.00 / $6,437.00
| Professional | | $4,757.00 | $5,364.00 | $6,437.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.24 / $2,750.39 / $5,265.24
| Professional | | $2,734.24 | $2,750.39 | $5,265.24 |
- 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
- $2,657.46 / $6,150.09 / $8,768.77
| Professional | | $2,657.46 | $6,150.09 | $8,768.77 |