- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,607.48 / $2,607.48 / $2,607.48
| Professional | | $2,607.48 | $2,607.48 | $2,607.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,889.00 / $6,641.00 / $7,969.00
| Professional | | $5,889.00 | $6,641.00 | $7,969.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,346.67 / $3,676.57 / $6,225.51
| Professional | | $2,346.67 | $3,676.57 | $6,225.51 |
- 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
- $1,949.27 / $5,988.61 / $10,401.59
| Professional | | $1,949.27 | $5,988.61 | $10,401.59 |