- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,644.00 / $5,644.00 / $5,644.00
| Professional | | $5,644.00 | $5,644.00 | $5,644.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,297.63 / $3,644.75 / $4,686.10
| Professional | | $3,297.63 | $3,644.75 | $4,686.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,032.69 / $6,459.75 / $7,540.86
| Professional | | $6,032.69 | $6,459.75 | $7,540.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,640.84 / $8,640.84 / $8,640.84
| Facility | | $8,640.84 | $8,640.84 | $8,640.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,412.71 / $2,412.71 / $5,780.48
| Professional | | $2,412.71 | $2,412.71 | $5,780.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,507.95 / $2,136.26
| Professional | | $1,055.57 | $1,507.95 | $2,136.26 |