- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,594.34 / $2,594.34 / $2,594.34
| Professional | | $2,594.34 | $2,594.34 | $2,594.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,928.00 / $6,685.00 / $8,022.00
| Professional | | $5,928.00 | $6,685.00 | $8,022.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,659.83 / $3,669.51 / $6,195.15
| Professional | | $3,659.83 | $3,669.51 | $6,195.15 |
- 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
- $4,085.95 / $8,519.48 / $10,537.55
| Professional | | $4,085.95 | $8,519.48 | $10,537.55 |