- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,477.85 / $2,477.85 / $2,477.85
| Professional | | $2,477.85 | $2,477.85 | $2,477.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,907.00 / $5,888.00 / $9,479.00
| Professional | | $4,907.00 | $5,888.00 | $9,479.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,266.17 / $4,099.38 / $5,708.43
| Professional | | $3,266.17 | $4,099.38 | $5,708.43 |
- 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
- $3,678.40 / $5,438.47 / $9,745.57
| Professional | | $3,678.40 | $5,438.47 | $9,745.57 |