- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,448.05 / $3,448.05 / $3,448.05
| Professional | | $3,448.05 | $3,448.05 | $3,448.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,876.00 / $8,881.00 / $10,657.00
| Professional | | $7,876.00 | $8,881.00 | $10,657.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,547.50 / $4,865.66 / $8,284.87
| Professional | | $4,547.50 | $4,865.66 | $8,284.87 |
- 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
- $4,665.00 / $8,807.12 / $13,845.46
| Professional | | $4,665.00 | $8,807.12 | $13,845.46 |