- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.01 / $1,601.01 / $1,601.01
| Professional | | $1,601.01 | $1,601.01 | $1,601.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,639.00 / $4,103.00 / $4,924.00
| Professional | | $3,639.00 | $4,103.00 | $4,924.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.31 / $2,273.94 / $3,830.72
| Professional | | $2,264.31 | $2,273.94 | $3,830.72 |
- 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
- $1,920.86 / $4,150.00 / $6,553.81
| Professional | | $1,920.86 | $4,150.00 | $6,553.81 |