- 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
- $16,820.00 / $23,185.00 / $23,185.00
| Professional | | $16,820.00 | $23,185.00 | $23,185.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,328.78 / $5,328.78 / $5,328.78
| Facility | | $5,328.78 | $5,328.78 | $5,328.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,110.93 / $4,405.82 / $33,500.00
| Professional | | $3,110.93 | $4,405.82 | $33,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,110.93 / $3,110.93 / $4,405.82
| Professional | | $3,110.93 | $3,110.93 | $4,405.82 |