- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,496.52 / $2,496.52 / $2,496.52
| Professional | | $2,496.52 | $2,496.52 | $2,496.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,110.00 / $6,132.00 / $9,870.00
| Professional | | $5,110.00 | $6,132.00 | $9,870.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,192.90 / $4,130.62 / $5,951.36
| Professional | | $3,192.90 | $4,130.62 | $5,951.36 |
- 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
- $2,619.09 / $5,046.35 / $8,447.39
| Professional | | $2,619.09 | $5,046.35 | $8,447.39 |