- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,033.02 / $2,033.02 / $2,033.02
| Professional | | $2,033.02 | $2,033.02 | $2,033.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,635.00 / $5,029.00 / $6,035.00
| Professional | | $4,635.00 | $5,029.00 | $6,035.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,652.76 / $3,361.92 / $4,736.77
| Professional | | $2,652.76 | $3,361.92 | $4,736.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,985.40 / $5,064.66 / $8,115.35
| Professional | | $2,985.40 | $5,064.66 | $8,115.35 |