- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,857.20 / $3,857.20 / $3,857.20
| Professional | | $3,857.20 | $3,857.20 | $3,857.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.57 / $4,321.80 / $4,321.80
| Facility | | $775.57 | $4,321.80 | $4,321.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.15 / $3,673.53 / $14,850.00
| Professional | | $724.15 | $3,673.53 | $14,850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,318.75 / $4,088.97 / $6,482.52
| Professional | | $2,318.75 | $4,088.97 | $6,482.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,502.59 / $2,896.60 / $5,561.30
| Professional | | $2,502.59 | $2,896.60 | $5,561.30 |