- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.41 / $2,159.41 / $2,159.41
| Professional | | $2,159.41 | $2,159.41 | $2,159.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,934.00 / $5,564.00 / $6,677.00
| Professional | | $4,934.00 | $5,564.00 | $6,677.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,131.63 / $3,253.64 / $5,315.50
| Professional | | $3,131.63 | $3,253.64 | $5,315.50 |
- 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
- $2,757.89 / $7,133.32 / $9,088.20
| Professional | | $2,757.89 | $7,133.32 | $9,088.20 |