- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,047.09 / $3,668.78 / $5,967.26
| Professional | | $3,047.09 | $3,668.78 | $5,967.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.00 / $1,165.00 / $1,303.00
| Professional | | $1,165.00 | $1,165.00 | $1,303.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.20 / $820.50 / $1,805.90
| Professional | | $705.20 | $820.50 | $1,805.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,531.29 / $18,009.95 / $26,542.00
| Facility | | $2,531.29 | $18,009.95 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,677.33 / $6,677.33 / $6,677.33
| Professional | | $6,677.33 | $6,677.33 | $6,677.33 |