- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,445.17 / $3,765.42 / $3,986.91
| Professional | | $2,445.17 | $3,765.42 | $3,986.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,421.80 / $3,421.80 / $3,421.80
| Professional | | $3,421.80 | $3,421.80 | $3,421.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $3,655.97
| Facility | | $3,655.97 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.57 / $3,655.97 / $5,865.00
| Professional | | $408.57 | $3,655.97 | $5,865.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.45 / $1,878.68 / $4,017.50
| Professional | | $1,252.45 | $1,878.68 | $4,017.50 |