- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.65 / $2,225.65 / $2,225.65
| Professional | | $2,225.65 | $2,225.65 | $2,225.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,082.00 / $5,731.00 / $6,877.00
| Professional | | $5,082.00 | $5,731.00 | $6,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,792.85 / $3,067.53 / $5,213.10
| Professional | | $1,792.85 | $3,067.53 | $5,213.10 |
- 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
- $1,445.81 / $4,491.22 / $8,334.45
| Professional | | $1,445.81 | $4,491.22 | $8,334.45 |