- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,473.92 / $3,837.94 / $5,689.68
| Professional | | $3,473.92 | $3,837.94 | $5,689.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,957.00 / $13,148.00 / $20,342.00
| Professional | | $10,957.00 | $13,148.00 | $20,342.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,305.05 / $6,936.84 / $9,383.67
| Professional | | $4,305.05 | $6,936.84 | $9,383.67 |
- 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
- $4,203.21 / $7,775.48 / $14,723.26
| Professional | | $4,203.21 | $7,775.48 | $14,723.26 |