- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,093.50 / $2,093.50 / $2,093.50
| Professional | | $2,093.50 | $2,093.50 | $2,093.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,288.00 / $5,146.00 / $8,284.00
| Professional | | $4,288.00 | $5,146.00 | $8,284.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,646.83 / $3,474.21 / $4,971.55
| Professional | | $2,646.83 | $3,474.21 | $4,971.55 |
- 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
- $2,970.00 / $5,057.18 / $8,137.81
| Professional | | $2,970.00 | $5,057.18 | $8,137.81 |