- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.03 / $2,058.03 / $2,058.03
| Professional | | $2,058.03 | $2,058.03 | $2,058.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,030.00 / $4,836.00 / $6,044.00
| Professional | | $4,030.00 | $4,836.00 | $6,044.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,583.57 / $3,407.06 / $4,514.18
| Professional | | $2,583.57 | $3,407.06 | $4,514.18 |
- 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
- $2,907.30 / $5,814.59 / $7,768.19
| Professional | | $2,907.30 | $5,814.59 | $7,768.19 |