- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,508.84 / $4,407.00 / $4,666.22
| Professional | | $2,508.84 | $4,407.00 | $4,666.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,036.10 / $4,036.10 / $4,036.10
| Professional | | $4,036.10 | $4,036.10 | $4,036.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $1,642.21
| Facility | | $1,642.21 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.42 / $1,642.21 / $6,918.75
| Professional | | $470.42 | $1,642.21 | $6,918.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.28 / $2,938.92 / $4,687.99
| Professional | | $1,959.28 | $2,938.92 | $4,687.99 |