- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,279.23 / $2,279.23 / $2,279.23
| Professional | | $2,279.23 | $2,279.23 | $2,279.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,136.00 / $5,792.00 / $6,950.00
| Professional | | $5,136.00 | $5,792.00 | $6,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,257.23 / $3,667.37 / $5,490.97
| Professional | | $3,257.23 | $3,667.37 | $5,490.97 |
- 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
- $4,157.10 / $7,501.41 / $13,261.90
| Professional | | $4,157.10 | $7,501.41 | $13,261.90 |