- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,917.17 / $5,920.41 / $9,629.51
| Professional | | $4,917.17 | $5,920.41 | $9,629.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.00 / $1,888.00 / $2,161.00
| Professional | | $1,888.00 | $1,888.00 | $2,161.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.00 / $1,456.10 / $2,999.50
| Professional | | $1,262.00 | $1,456.10 | $2,999.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $4,156.71 / $5,661.36
| Facility | | $55.00 | $4,156.71 | $5,661.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,378.98 / $7,378.98 / $7,378.98
| Professional | | $7,378.98 | $7,378.98 | $7,378.98 |