- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,448.00 / $7,136.14 / $8,549.90
| Professional | | $6,448.00 | $7,136.14 | $8,549.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.00 / $405.00 / $405.00
| Professional | | $405.00 | $405.00 | $405.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,683.20 / $2,683.20 / $2,683.20
| Professional | | $2,683.20 | $2,683.20 | $2,683.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,809.58 / $2,659.53 / $2,720.74
| Facility | | $1,809.58 | $2,659.53 | $2,720.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,943.92 / $6,016.53 / $6,016.53
| Professional | | $5,943.92 | $6,016.53 | $6,016.53 |