- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,145.79 / $2,145.79 / $2,145.79
| Professional | | $2,145.79 | $2,145.79 | $2,145.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,394.00 / $5,273.00 / $8,488.00
| Professional | | $4,394.00 | $5,273.00 | $8,488.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,759.36 / $3,555.26 / $5,169.51
| Professional | | $2,759.36 | $3,555.26 | $5,169.51 |
- 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
- $3,093.75 / $6,723.48 / $8,395.19
| Professional | | $3,093.75 | $6,723.48 | $8,395.19 |