- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,124.84 / $5,906.94 / $7,742.25
| Professional | | $4,124.84 | $5,906.94 | $7,742.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,937.94 / $6,937.94 / $6,937.94
| Professional | | $6,937.94 | $6,937.94 | $6,937.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,900.00 / $5,900.00 / $6,018.00
| Facility | | $5,900.00 | $5,900.00 | $6,018.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $763.91 / $5,900.00 / $11,268.75
| Professional | | $763.91 | $5,900.00 | $11,268.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.20 / $4,876.80 / $7,721.60
| Professional | | $3,251.20 | $4,876.80 | $7,721.60 |