- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,036.34 / $3,655.83 / $5,946.19
| Professional | | $3,036.34 | $3,655.83 | $5,946.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.00 / $1,180.00 / $1,284.00
| Professional | | $1,180.00 | $1,180.00 | $1,284.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.70 / $1,013.20 / $1,976.10
| Professional | | $851.70 | $1,013.20 | $1,976.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,191.58 / $8,444.70 / $26,542.00
| Facility | | $2,191.58 | $8,444.70 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,691.35 / $5,691.35 / $5,691.35
| Professional | | $5,691.35 | $5,691.35 | $5,691.35 |