- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.67 / $2,255.67 / $2,255.67
| Professional | | $2,255.67 | $2,255.67 | $2,255.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,152.00 / $5,810.00 / $6,972.00
| Professional | | $5,152.00 | $5,810.00 | $6,972.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,960.62 / $2,974.02 / $5,704.55
| Professional | | $2,960.62 | $2,974.02 | $5,704.55 |
- 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
- $2,741.78 / $6,647.30 / $9,209.62
| Professional | | $2,741.78 | $6,647.30 | $9,209.62 |