- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,593.17 / $2,593.17 / $2,593.17
| Professional | | $2,593.17 | $2,593.17 | $2,593.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,306.00 / $6,367.00 / $10,249.00
| Professional | | $5,306.00 | $6,367.00 | $10,249.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,331.69 / $4,288.24 / $6,267.50
| Professional | | $3,331.69 | $4,288.24 | $6,267.50 |
- 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
- $3,729.55 / $6,330.40 / $10,144.20
| Professional | | $3,729.55 | $6,330.40 | $10,144.20 |