- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,167.44 / $2,167.44 / $2,167.44
| Professional | | $2,167.44 | $2,167.44 | $2,167.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,949.00 / $5,580.00 / $6,696.00
| Professional | | $4,949.00 | $5,580.00 | $6,696.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,047.01 / $2,986.53 / $5,074.06
| Professional | | $2,047.01 | $2,986.53 | $5,074.06 |
- 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
- $2,286.35 / $4,870.47 / $8,213.04
| Professional | | $2,286.35 | $4,870.47 | $8,213.04 |