- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,733.14 / $2,733.14 / $2,733.14
| Professional | | $2,733.14 | $2,733.14 | $2,733.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,751.00 / $6,335.00 / $7,602.00
| Professional | | $4,751.00 | $6,335.00 | $7,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,355.41 / $3,327.97 / $4,991.96
| Professional | | $2,355.41 | $3,327.97 | $4,991.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,944.48 / $4,791.56 / $8,504.52
| Professional | | $2,944.48 | $4,791.56 | $8,504.52 |