- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,175.01 / $2,175.01 / $2,175.01
| Professional | | $2,175.01 | $2,175.01 | $2,175.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,459.00 / $5,351.00 / $8,614.00
| Professional | | $4,459.00 | $5,351.00 | $8,614.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,803.52 / $3,608.11 / $5,213.27
| Professional | | $2,803.52 | $3,608.11 | $5,213.27 |
- 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
- $3,143.79 / $5,332.74 / $8,540.39
| Professional | | $3,143.79 | $5,332.74 | $8,540.39 |