- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,057.25 / $3,057.25 / $3,057.25
| Professional | | $3,057.25 | $3,057.25 | $3,057.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,256.00 / $7,507.00 / $12,085.00
| Professional | | $6,256.00 | $7,507.00 | $12,085.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,958.45 / $5,052.49 / $7,336.38
| Professional | | $3,958.45 | $5,052.49 | $7,336.38 |
- 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
- $4,430.25 / $9,653.25 / $11,773.07
| Professional | | $4,430.25 | $9,653.25 | $11,773.07 |