- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.42 / $2,545.42 / $2,545.42
| Professional | | $2,545.42 | $2,545.42 | $2,545.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,212.00 / $6,254.00 / $10,067.00
| Professional | | $5,212.00 | $6,254.00 | $10,067.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,314.64 / $4,214.96 / $5,668.14
| Professional | | $3,314.64 | $4,214.96 | $5,668.14 |
- 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
- $3,718.00 / $6,289.73 / $10,039.92
| Professional | | $3,718.00 | $6,289.73 | $10,039.92 |