- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,457.28 / $6,570.72 / $10,687.24
| Professional | | $5,457.28 | $6,570.72 | $10,687.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,131.00 / $2,131.00 / $2,331.00
| Professional | | $2,131.00 | $2,131.00 | $2,331.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.20 / $1,628.20 / $3,222.00
| Professional | | $1,436.20 | $1,628.20 | $3,222.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $4,353.93 / $6,084.33
| Facility | | $55.00 | $4,353.93 | $6,084.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,423.81 / $8,423.81 / $8,423.81
| Professional | | $8,423.81 | $8,423.81 | $8,423.81 |