- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,055.46 / $3,678.85 / $5,983.64
| Professional | | $3,055.46 | $3,678.85 | $5,983.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.00 / $1,177.00 / $1,204.00
| Professional | | $1,177.00 | $1,177.00 | $1,204.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.50 / $1,139.50 / $1,892.20
| Professional | | $1,005.50 | $1,139.50 | $1,892.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,190.71 / $3,775.00 / $13,851.75
| Facility | | $2,190.71 | $3,775.00 | $13,851.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,563.45 / $4,727.72 / $4,727.72
| Professional | | $4,563.45 | $4,727.72 | $4,727.72 |