- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.40 / $2,138.40 / $2,138.40
| Professional | | $2,138.40 | $2,138.40 | $2,138.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,885.00 / $5,509.00 / $6,611.00
| Professional | | $4,885.00 | $5,509.00 | $6,611.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.71 / $2,951.48 / $5,016.28
| Professional | | $2,005.71 | $2,951.48 | $5,016.28 |
- 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
- $2,237.94 / $5,289.70 / $8,054.62
| Professional | | $2,237.94 | $5,289.70 | $8,054.62 |