- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,387.65 / $4,078.82 / $6,634.18
| Professional | | $3,387.65 | $4,078.82 | $6,634.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.00 / $1,310.00 / $1,338.00
| Professional | | $1,310.00 | $1,310.00 | $1,338.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.40 / $1,689.20 / $2,097.80
| Professional | | $1,059.40 | $1,689.20 | $2,097.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,436.26 / $2,800.00 / $22,807.05
| Facility | | $2,436.26 | $2,800.00 | $22,807.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,070.50 / $5,235.97 / $5,235.97
| Professional | | $5,070.50 | $5,235.97 | $5,235.97 |