- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,261.31 / $6,334.76 / $10,303.45
| Professional | | $5,261.31 | $6,334.76 | $10,303.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.00 / $2,052.00 / $2,247.00
| Professional | | $2,052.00 | $2,052.00 | $2,247.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.70 / $1,597.00 / $3,107.70
| Professional | | $1,377.70 | $1,597.00 | $3,107.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $4,197.63 / $5,827.20
| Facility | | $55.00 | $4,197.63 | $5,827.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,454.23 / $7,454.23 / $7,454.23
| Professional | | $7,454.23 | $7,454.23 | $7,454.23 |