- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,623.74 / $3,623.74 / $3,623.74
| Professional | | $3,623.74 | $3,623.74 | $3,623.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,417.00 / $8,900.00 / $14,328.00
| Professional | | $7,417.00 | $8,900.00 | $14,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,745.72 / $5,986.96 / $8,782.00
| Professional | | $4,745.72 | $5,986.96 | $8,782.00 |
- 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
- $5,310.25 / $8,977.28 / $14,315.41
| Professional | | $5,310.25 | $8,977.28 | $14,315.41 |