- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,094.34 / $2,094.34 / $2,094.34
| Professional | | $2,094.34 | $2,094.34 | $2,094.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,785.00 / $5,396.00 / $6,475.00
| Professional | | $4,785.00 | $5,396.00 | $6,475.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,755.46 / $3,008.22 / $5,311.87
| Professional | | $2,755.46 | $3,008.22 | $5,311.87 |
- 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
- $2,529.56 / $6,707.80 / $8,731.81
| Professional | | $2,529.56 | $6,707.80 | $8,731.81 |