- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,587.94 / $2,587.94 / $2,587.94
| Professional | | $2,587.94 | $2,587.94 | $2,587.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,877.00 / $6,628.00 / $7,954.00
| Professional | | $5,877.00 | $6,628.00 | $7,954.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,662.87 / $3,717.54 / $6,192.85
| Professional | | $3,662.87 | $3,717.54 | $6,192.85 |
- 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
- $3,065.78 / $8,288.49 / $10,566.60
| Professional | | $3,065.78 | $8,288.49 | $10,566.60 |