- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,268.48 / $5,759.26 / $6,098.04
| Professional | | $3,268.48 | $5,759.26 | $6,098.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,843.00 / $5,843.00 / $5,843.00
| Professional | | $5,843.00 | $5,843.00 | $5,843.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $4,775.22
| Facility | | $4,775.22 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.41 / $4,775.22 / $9,011.25
| Professional | | $615.41 | $4,775.22 | $9,011.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,560.48 / $3,840.72 / $6,081.14
| Professional | | $2,560.48 | $3,840.72 | $6,081.14 |