- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,229.16 / $15,928.27 / $25,907.25
| Professional | | $13,229.16 | $15,928.27 | $25,907.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,789.00 / $5,789.00 / $5,789.00
| Professional | | $5,789.00 | $5,789.00 | $5,789.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,223.60 / $5,589.50 / $8,010.30
| Professional | | $5,223.60 | $5,589.50 | $8,010.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $17,683.50 / $17,814.83
| Facility | | $55.00 | $17,683.50 | $17,814.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,267.56 / $22,267.56 / $22,267.56
| Professional | | $22,267.56 | $22,267.56 | $22,267.56 |