- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.16 / $4,306.22 / $4,540.77
| Professional | | $2,465.16 | $4,306.22 | $4,540.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,407.00 / $4,407.00 / $4,407.00
| Professional | | $4,407.00 | $4,407.00 | $4,407.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $3,282.89
| Facility | | $3,282.89 | $3,282.89 | $3,282.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.28 / $3,282.89 / $6,731.25
| Professional | | $456.28 | $3,282.89 | $6,731.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.64 / $2,859.96 / $4,606.37
| Professional | | $1,906.64 | $2,859.96 | $4,606.37 |