- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.01 / $1,546.01 / $1,546.01
| Professional | | $1,546.01 | $1,546.01 | $1,546.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,512.00 / $3,960.00 / $4,752.00
| Professional | | $3,512.00 | $3,960.00 | $4,752.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,213.55 / $2,217.10 / $3,723.32
| Professional | | $2,213.55 | $2,217.10 | $3,723.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,816.64 / $4,944.51 / $6,346.57
| Professional | | $1,816.64 | $4,944.51 | $6,346.57 |