- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,129.28 / $3,081.34 / $3,995.64
| Professional | | $2,129.28 | $3,081.34 | $3,995.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,671.90 / $3,671.90 / $3,671.90
| Professional | | $3,671.90 | $3,671.90 | $3,671.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.88 / $2,673.00 / $5,073.75
| Professional | | $343.88 | $2,673.00 | $5,073.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.31 / $1,824.44 / $3,339.58
| Professional | | $1,119.31 | $1,824.44 | $3,339.58 |