- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,690.80 / $2,690.80 / $2,690.80
| Professional | | $2,690.80 | $2,690.80 | $2,690.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,185.00 / $7,422.00 / $11,947.00
| Professional | | $6,185.00 | $7,422.00 | $11,947.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,718.49 / $5,020.22 / $6,360.56
| Professional | | $3,718.49 | $5,020.22 | $6,360.56 |
- 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
- $4,173.41 / $8,370.27 / $9,864.40
| Professional | | $4,173.41 | $8,370.27 | $9,864.40 |