- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.92 / $2,400.50 / $2,932.50
| Professional | | $2,323.92 | $2,400.50 | $2,932.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,912.00 / $5,894.00 / $9,490.00
| Professional | | $4,912.00 | $5,894.00 | $9,490.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,899.46 / $4,561.56 / $5,949.56
| Professional | | $2,899.46 | $4,561.56 | $5,949.56 |
- 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
- $3,409.41 / $4,846.43 / $7,983.27
| Professional | | $3,409.41 | $4,846.43 | $7,983.27 |