- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.01 / $2,390.01 / $2,390.01
| Professional | | $2,390.01 | $2,390.01 | $2,390.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,462.00 / $6,159.00 / $7,391.00
| Professional | | $5,462.00 | $6,159.00 | $7,391.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,375.54 / $3,550.60 / $6,067.44
| Professional | | $3,375.54 | $3,550.60 | $6,067.44 |
- 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
- $2,928.41 / $7,508.59 / $9,720.48
| Professional | | $2,928.41 | $7,508.59 | $9,720.48 |