- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.11 / $4,130.63 / $5,859.05
| Professional | | $3,981.11 | $4,130.63 | $5,859.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,345.00 / $13,614.00 / $21,064.00
| Professional | | $11,345.00 | $13,614.00 | $21,064.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,473.43 / $7,179.69 / $11,008.91
| Professional | | $4,473.43 | $7,179.69 | $11,008.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,448.92 / $8,212.12 / $17,330.29
| Professional | | $4,448.92 | $8,212.12 | $17,330.29 |