- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.77 / $1,989.77 / $1,989.77
| Professional | | $1,989.77 | $1,989.77 | $1,989.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,552.00 / $5,133.00 / $6,160.00
| Professional | | $4,552.00 | $5,133.00 | $6,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,775.87 / $2,819.44 / $4,755.14
| Professional | | $2,775.87 | $2,819.44 | $4,755.14 |
- 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
- $3,093.20 / $6,495.62 / $8,354.28
| Professional | | $3,093.20 | $6,495.62 | $8,354.28 |