- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,568.56 / $2,568.56 / $2,568.56
| Professional | | $2,568.56 | $2,568.56 | $2,568.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,257.00 / $6,308.00 / $10,156.00
| Professional | | $5,257.00 | $6,308.00 | $10,156.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,338.46 / $4,249.41 / $6,130.71
| Professional | | $3,338.46 | $4,249.41 | $6,130.71 |
- 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
- $3,740.56 / $6,325.42 / $10,092.70
| Professional | | $3,740.56 | $6,325.42 | $10,092.70 |