- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.06 / $1,877.06 / $1,877.06
| Professional | | $1,877.06 | $1,877.06 | $1,877.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,289.00 / $4,837.00 / $5,804.00
| Professional | | $4,289.00 | $4,837.00 | $5,804.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.62 / $2,481.21 / $4,485.96
| Professional | | $2,454.62 | $2,481.21 | $4,485.96 |
- 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
- $2,281.81 / $4,265.37 / $7,876.43
| Professional | | $2,281.81 | $4,265.37 | $7,876.43 |