- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,301.77 / $2,301.77 / $2,301.77
| Professional | | $2,301.77 | $2,301.77 | $2,301.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,714.00 / $5,657.00 / $9,106.00
| Professional | | $4,714.00 | $5,657.00 | $9,106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,967.30 / $3,812.10 / $5,522.42
| Professional | | $2,967.30 | $3,812.10 | $5,522.42 |
- 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
- $3,325.31 / $5,634.87 / $9,012.96
| Professional | | $3,325.31 | $5,634.87 | $9,012.96 |