- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,223.29 / $3,893.17 / $4,122.18
| Professional | | $2,223.29 | $3,893.17 | $4,122.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,975.00 / $3,975.00 / $3,975.00
| Professional | | $3,975.00 | $3,975.00 | $3,975.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.13 / $3,248.38 / $6,123.75
| Professional | | $415.13 | $3,248.38 | $6,123.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.84 / $2,596.26 / $4,110.75
| Professional | | $1,730.84 | $2,596.26 | $4,110.75 |