- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,327.29 / $3,052.23 / $3,237.94
| Professional | | $2,327.29 | $3,052.23 | $3,237.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,347.03 / $3,638.08 / $3,638.08
| Professional | | $3,347.03 | $3,638.08 | $3,638.08 |
- 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
- $946.43 / $1,588.21 / $2,366.07
| Professional | | $946.43 | $1,588.21 | $2,366.07 |