- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,153.85 / $2,153.85 / $2,153.85
| Professional | | $2,153.85 | $2,153.85 | $2,153.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,918.00 / $5,546.00 / $6,655.00
| Professional | | $4,918.00 | $5,546.00 | $6,655.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,839.88 / $2,844.70 / $5,478.09
| Professional | | $2,839.88 | $2,844.70 | $5,478.09 |
- 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
- $3,175.15 / $7,066.20 / $8,887.54
| Professional | | $3,175.15 | $7,066.20 | $8,887.54 |