- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,131.25 / $5,131.25 / $8,986.20
| Professional | | $5,131.25 | $5,131.25 | $8,986.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,022.00 / $10,022.00 / $10,022.00
| Professional | | $10,022.00 | $10,022.00 | $10,022.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $4,978.93 / $4,978.93
| Facility | | $4,978.93 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,400.00 / $4,400.00 / $4,978.93
| Professional | | $4,400.00 | $4,400.00 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,901.24 / $3,377.76 / $5,629.60
| Professional | | $2,901.24 | $3,377.76 | $5,629.60 |