- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,882.78 / $2,882.78 / $2,882.78
| Professional | | $2,882.78 | $2,882.78 | $2,882.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,811.00 / $6,973.00 / $11,225.00
| Professional | | $5,811.00 | $6,973.00 | $11,225.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,435.43 / $4,729.08 / $6,652.59
| Professional | | $3,435.43 | $4,729.08 | $6,652.59 |
- 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
- $3,863.75 / $6,678.17 / $10,945.45
| Professional | | $3,863.75 | $6,678.17 | $10,945.45 |