- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.31 / $3,668.12 / $5,356.08
| Professional | | $2,857.31 | $3,668.12 | $5,356.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,596.71 / $4,596.71 / $4,596.71
| Professional | | $4,596.71 | $4,596.71 | $4,596.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $2,958.00
| Facility | | $2,900.00 | $2,900.00 | $2,958.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.34 / $2,900.00 / $7,878.75
| Professional | | $480.34 | $2,900.00 | $7,878.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.98 / $2,687.49 / $4,529.07
| Professional | | $1,906.98 | $2,687.49 | $4,529.07 |