- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.48 / $2,139.48 / $2,139.48
| Professional | | $2,139.48 | $2,139.48 | $2,139.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,381.00 / $5,257.00 / $8,464.00
| Professional | | $4,381.00 | $5,257.00 | $8,464.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,497.32 / $3,542.14 / $5,103.62
| Professional | | $2,497.32 | $3,542.14 | $5,103.62 |
- 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
- $2,795.10 / $5,590.20 / $7,739.14
| Professional | | $2,795.10 | $5,590.20 | $7,739.14 |