- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.75 / $3,190.65 / $3,378.33
| Professional | | $1,959.75 | $3,190.65 | $3,378.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,864.10 / $2,864.10 / $2,864.10
| Professional | | $2,864.10 | $2,864.10 | $2,864.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $2,671.66 / $4,515.00
| Professional | | $286.64 | $2,671.66 | $4,515.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.44 / $1,552.10 / $2,894.35
| Professional | | $1,134.44 | $1,552.10 | $2,894.35 |