- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,003.10 / $2,003.10 / $2,003.10
| Professional | | $2,003.10 | $2,003.10 | $2,003.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,101.00 / $4,921.00 / $7,921.00
| Professional | | $4,101.00 | $4,921.00 | $7,921.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,576.03 / $3,319.40 / $4,832.18
| Professional | | $2,576.03 | $3,319.40 | $4,832.18 |
- 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
- $2,890.25 / $4,496.49 / $7,854.01
| Professional | | $2,890.25 | $4,496.49 | $7,854.01 |