- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,106.84 / $3,740.72 / $6,084.26
| Professional | | $3,106.84 | $3,740.72 | $6,084.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.00 / $1,234.00 / $1,320.00
| Professional | | $1,234.00 | $1,234.00 | $1,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.70 / $1,331.20 / $1,820.20
| Professional | | $1,125.70 | $1,331.20 | $1,820.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,791.22 / $3,459.78
| Facility | | $55.00 | $2,791.22 | $3,459.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,624.00 / $7,624.00 / $7,624.00
| Professional | | $7,624.00 | $7,624.00 | $7,624.00 |