- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,127.07 / $2,127.07 / $2,127.07
| Professional | | $2,127.07 | $2,127.07 | $2,127.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,864.00 / $5,485.00 / $6,582.00
| Professional | | $4,864.00 | $5,485.00 | $6,582.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,001.28 / $3,060.14 / $5,101.39
| Professional | | $3,001.28 | $3,060.14 | $5,101.39 |
- 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
- $2,427.71 / $5,561.83 / $8,685.58
| Professional | | $2,427.71 | $5,561.83 | $8,685.58 |