- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,999.29 / $3,611.23 / $5,873.65
| Professional | | $2,999.29 | $3,611.23 | $5,873.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.00 / $1,165.00 / $1,190.00
| Professional | | $1,165.00 | $1,165.00 | $1,190.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.60 / $1,045.30 / $1,858.30
| Professional | | $888.60 | $1,045.30 | $1,858.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,162.23 / $2,800.00 / $22,807.05
| Facility | | $2,162.23 | $2,800.00 | $22,807.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,208.52 / $4,365.45 / $4,365.45
| Professional | | $4,208.52 | $4,365.45 | $4,365.45 |