- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.03 / $2,012.03 / $2,012.03
| Professional | | $2,012.03 | $2,012.03 | $2,012.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,600.00 / $5,187.00 / $6,224.00
| Professional | | $4,600.00 | $5,187.00 | $6,224.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,862.89 / $2,887.40 / $4,826.32
| Professional | | $2,862.89 | $2,887.40 | $4,826.32 |
- 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
- $3,219.15 / $6,438.30 / $8,242.09
| Professional | | $3,219.15 | $6,438.30 | $8,242.09 |