- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,075.03 / $5,075.03 / $5,075.03
| Professional | | $5,075.03 | $5,075.03 | $5,075.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25,169.20 / $25,169.20 / $25,169.20
| Professional | | $25,169.20 | $25,169.20 | $25,169.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,173.92 / $3,173.92 / $3,174.00
| Professional | | $3,173.92 | $3,173.92 | $3,174.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $6,648.41 / $45,058.00
| Professional | | $100.00 | $6,648.41 | $45,058.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,643.66 / $3,731.29 / $6,223.79
| Professional | | $2,643.66 | $3,731.29 | $6,223.79 |