- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.48 / $2,053.48 / $2,053.48
| Professional | | $2,053.48 | $2,053.48 | $2,053.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,694.00 / $5,293.00 / $6,352.00
| Professional | | $4,694.00 | $5,293.00 | $6,352.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,115.92 / $3,362.49 / $5,662.69
| Professional | | $3,115.92 | $3,362.49 | $5,662.69 |
- 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
- $2,633.30 / $5,895.48 / $8,665.81
| Professional | | $2,633.30 | $5,895.48 | $8,665.81 |