- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,061.90 / $6,061.90 / $10,616.00
| Professional | | $6,061.90 | $6,061.90 | $10,616.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,839.60 / $11,839.60 / $11,839.60
| Professional | | $11,839.60 | $11,839.60 | $11,839.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $7,447.14
| Facility | | $7,447.14 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $7,447.14
| Professional | | $7,447.14 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,904.84 / $3,427.44 / $5,163.00
| Professional | | $2,904.84 | $3,427.44 | $5,163.00 |