- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.28 / $3,330.68 / $5,417.33
| Professional | | $2,766.28 | $3,330.68 | $5,417.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.00 / $1,073.00 / $1,095.00
| Professional | | $1,073.00 | $1,073.00 | $1,095.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.00 / $1,046.50 / $1,711.90
| Professional | | $924.00 | $1,046.50 | $1,711.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,989.05 / $2,800.00 / $22,807.05
| Facility | | $1,989.05 | $2,800.00 | $22,807.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,157.81 / $4,349.77 / $4,349.77
| Professional | | $4,157.81 | $4,349.77 | $4,349.77 |