- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,174.42 / $3,174.42 / $3,174.42
| Professional | | $3,174.42 | $3,174.42 | $3,174.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,498.00 / $7,798.00 / $12,553.00
| Professional | | $6,498.00 | $7,798.00 | $12,553.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,099.35 / $5,253.80 / $7,666.28
| Professional | | $4,099.35 | $5,253.80 | $7,666.28 |
- 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
- $4,592.50 / $7,779.59 / $12,439.67
| Professional | | $4,592.50 | $7,779.59 | $12,439.67 |