- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,195.56 / $3,195.56 / $3,195.56
| Professional | | $3,195.56 | $3,195.56 | $3,195.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,252.00 / $8,178.00 / $9,814.00
| Professional | | $7,252.00 | $8,178.00 | $9,814.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,562.95 / $4,582.09 / $7,645.85
| Professional | | $4,562.95 | $4,582.09 | $7,645.85 |
- 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
- $5,083.64 / $10,167.29 / $13,000.67
| Professional | | $5,083.64 | $10,167.29 | $13,000.67 |