- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.02 / $1,857.02 / $1,857.02
| Professional | | $1,857.02 | $1,857.02 | $1,857.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,194.00 / $4,730.00 / $5,676.00
| Professional | | $4,194.00 | $4,730.00 | $5,676.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,038.75 / $3,038.75 / $3,038.75
| Professional | | $3,038.75 | $3,038.75 | $3,038.75 |
- 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
- $2,143.10 / $5,140.45 / $6,682.37
| Professional | | $2,143.10 | $5,140.45 | $6,682.37 |