- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,726.34 / $2,726.34 / $2,726.34
| Professional | | $2,726.34 | $2,726.34 | $2,726.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,234.00 / $7,030.00 / $8,436.00
| Professional | | $6,234.00 | $7,030.00 | $8,436.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,532.94 / $3,722.42 / $6,462.95
| Professional | | $3,532.94 | $3,722.42 | $6,462.95 |
- 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
- $4,147.56 / $8,869.66 / $10,798.93
| Professional | | $4,147.56 | $8,869.66 | $10,798.93 |