- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.65 / $2,299.65 / $2,299.65
| Professional | | $2,299.65 | $2,299.65 | $2,299.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,251.00 / $5,921.00 / $7,105.00
| Professional | | $5,251.00 | $5,921.00 | $7,105.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,030.43 / $3,051.42 / $5,843.12
| Professional | | $3,030.43 | $3,051.42 | $5,843.12 |
- 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
- $2,597.77 / $5,511.19 / $9,729.70
| Professional | | $2,597.77 | $5,511.19 | $9,729.70 |