- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,898.79 / $2,898.79 / $2,898.79
| Professional | | $2,898.79 | $2,898.79 | $2,898.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,469.00 / $6,563.00 / $10,564.00
| Professional | | $5,469.00 | $6,563.00 | $10,564.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,456.42 / $4,579.20 / $6,193.01
| Professional | | $3,456.42 | $4,579.20 | $6,193.01 |
- 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
- $3,022.68 / $7,817.71 / $10,603.56
| Professional | | $3,022.68 | $7,817.71 | $10,603.56 |