- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,298.18 / $5,175.14 / $8,417.34
| Professional | | $4,298.18 | $5,175.14 | $8,417.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.00 / $1,677.00 / $1,708.00
| Professional | | $1,677.00 | $1,677.00 | $1,708.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.30 / $1,575.00 / $2,663.70
| Professional | | $1,338.30 | $1,575.00 | $2,663.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,800.00 / $3,398.97 / $22,807.05
| Facility | | $2,800.00 | $3,398.97 | $22,807.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,084.60 / $6,308.29 / $6,308.29
| Professional | | $6,084.60 | $6,308.29 | $6,308.29 |