- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,302.96 / $3,302.96 / $3,302.96
| Professional | | $3,302.96 | $3,302.96 | $3,302.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,686.00 / $8,023.00 / $12,914.00
| Professional | | $6,686.00 | $8,023.00 | $12,914.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,158.58 / $5,422.51 / $7,663.30
| Professional | | $4,158.58 | $5,422.51 | $7,663.30 |
- 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
- $4,671.16 / $7,956.38 / $12,813.24
| Professional | | $4,671.16 | $7,956.38 | $12,813.24 |