- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.60 / $2,120.60 / $2,120.60
| Professional | | $2,120.60 | $2,120.60 | $2,120.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,342.00 / $5,210.00 / $8,387.00
| Professional | | $4,342.00 | $5,210.00 | $8,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,715.10 / $3,513.14 / $5,060.13
| Professional | | $2,715.10 | $3,513.14 | $5,060.13 |
- 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
- $3,044.26 / $6,652.05 / $8,304.14
| Professional | | $3,044.26 | $6,652.05 | $8,304.14 |