- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,335.94 / $2,335.94 / $2,335.94
| Professional | | $2,335.94 | $2,335.94 | $2,335.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,333.00 / $6,013.00 / $7,216.00
| Professional | | $5,333.00 | $6,013.00 | $7,216.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.16 / $3,221.15 / $5,459.52
| Professional | | $1,943.16 | $3,221.15 | $5,459.52 |
- 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
- $1,603.47 / $5,128.51 / $8,760.86
| Professional | | $1,603.47 | $5,128.51 | $8,760.86 |