- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.82 / $2,679.82 / $2,679.82
| Professional | | $2,679.82 | $2,679.82 | $2,679.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,083.00 / $6,859.00 / $8,231.00
| Professional | | $6,083.00 | $6,859.00 | $8,231.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,839.88 / $3,865.23 / $6,485.68
| Professional | | $3,839.88 | $3,865.23 | $6,485.68 |
- 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
- $3,185.16 / $8,617.39 / $11,016.73
| Professional | | $3,185.16 | $8,617.39 | $11,016.73 |