- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,436.59 / $6,587.86 / $6,587.86
| Professional | | $2,436.59 | $6,587.86 | $6,587.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,911.94 / $5,911.94 / $5,911.94
| Professional | | $5,911.94 | $5,911.94 | $5,911.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,587.86 / $6,785.50 / $21,047.41
| Facility | | $6,587.86 | $6,785.50 | $21,047.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,245.18 / $3,280.75 / $25,000.00
| Professional | | $3,245.18 | $3,280.75 | $25,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,245.18 / $3,280.75 / $25,000.00
| Professional | | $3,245.18 | $3,280.75 | $25,000.00 |