- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.55 / $2,406.55 / $2,406.55
| Professional | | $2,406.55 | $2,406.55 | $2,406.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,497.00 / $6,199.00 / $7,439.00
| Professional | | $5,497.00 | $6,199.00 | $7,439.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,652.15 / $3,656.50 / $6,110.00
| Professional | | $3,652.15 | $3,656.50 | $6,110.00 |
- 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
- $3,074.79 / $6,690.63 / $10,482.14
| Professional | | $3,074.79 | $6,690.63 | $10,482.14 |