- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,845.27 / $2,845.27 / $2,845.27
| Professional | | $2,845.27 | $2,845.27 | $2,845.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,734.00 / $6,881.00 / $11,076.00
| Professional | | $5,734.00 | $6,881.00 | $11,076.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,033.93 / $4,667.75 / $5,823.01
| Professional | | $3,033.93 | $4,667.75 | $5,823.01 |
- 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
- $2,753.62 / $6,846.40 / $9,011.65
| Professional | | $2,753.62 | $6,846.40 | $9,011.65 |