- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.55 / $2,102.55 / $2,102.55
| Professional | | $2,102.55 | $2,102.55 | $2,102.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,092.00 / $4,910.00 / $6,138.00
| Professional | | $4,092.00 | $4,910.00 | $6,138.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,862.68 / $3,505.66 / $4,956.29
| Professional | | $2,862.68 | $3,505.66 | $4,956.29 |
- 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
- $3,347.84 / $5,340.21 / $8,251.32
| Professional | | $3,347.84 | $5,340.21 | $8,251.32 |