- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.62 / $2,395.62 / $2,395.62
| Professional | | $2,395.62 | $2,395.62 | $2,395.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,906.00 / $5,887.00 / $9,476.00
| Professional | | $4,906.00 | $5,887.00 | $9,476.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,644.86 / $3,972.56 / $5,448.62
| Professional | | $2,644.86 | $3,972.56 | $5,448.62 |
- 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
- $2,974.40 / $7,030.40 / $7,490.04
| Professional | | $2,974.40 | $7,030.40 | $7,490.04 |