- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,704.13 / $2,704.13 / $2,704.13
| Professional | | $2,704.13 | $2,704.13 | $2,704.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,721.00 / $6,295.00 / $7,554.00
| Professional | | $4,721.00 | $6,295.00 | $7,554.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.54 / $3,586.85 / $5,380.27
| Professional | | $2,371.54 | $3,586.85 | $5,380.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,756.54 / $4,626.01 / $8,347.53
| Professional | | $2,756.54 | $4,626.01 | $8,347.53 |