- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,536.67 / $2,536.67 / $2,536.67
| Professional | | $2,536.67 | $2,536.67 | $2,536.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,193.00 / $6,232.00 / $10,031.00
| Professional | | $5,193.00 | $6,232.00 | $10,031.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,729.14 / $4,197.29 / $5,531.18
| Professional | | $2,729.14 | $4,197.29 | $5,531.18 |
- 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
- $3,055.25 / $5,713.15 / $8,055.94
| Professional | | $3,055.25 | $5,713.15 | $8,055.94 |