- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,746.54 / $3,617.68 / $4,122.47
| Professional | | $2,746.54 | $3,617.68 | $4,122.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,030.00 / $3,293.48 / $3,293.48
| Professional | | $3,030.00 | $3,293.48 | $3,293.48 |
- 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 / $1,682.64 / $2,804.40
| Professional | | $1,252.45 | $1,682.64 | $2,804.40 |