- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.88 / $2,010.88 / $2,010.88
| Professional | | $2,010.88 | $2,010.88 | $2,010.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,119.00 / $4,943.00 / $7,957.00
| Professional | | $4,119.00 | $4,943.00 | $7,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,459.05 / $3,331.40 / $4,229.54
| Professional | | $2,459.05 | $3,331.40 | $4,229.54 |
- 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
- $2,910.06 / $5,820.11 / $8,025.61
| Professional | | $2,910.06 | $5,820.11 | $8,025.61 |