- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.50 / $2,031.50 / $2,031.50
| Professional | | $2,031.50 | $2,031.50 | $2,031.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,642.00 / $5,235.00 / $6,282.00
| Professional | | $4,642.00 | $5,235.00 | $6,282.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,512.66 / $2,930.64 / $4,869.43
| Professional | | $2,512.66 | $2,930.64 | $4,869.43 |
- 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
- $2,070.54 / $5,631.99 / $8,284.32
| Professional | | $2,070.54 | $5,631.99 | $8,284.32 |