- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.98 / $4,163.39 / $4,408.29
| Professional | | $2,570.98 | $4,163.39 | $4,408.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,908.30 / $3,908.30 / $3,908.30
| Professional | | $3,908.30 | $3,908.30 | $3,908.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,621.85
| Facility | | $3,621.85 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.96 / $3,621.85 / $5,707.50
| Professional | | $386.96 | $3,621.85 | $5,707.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.80 / $1,852.20 / $3,868.78
| Professional | | $1,234.80 | $1,852.20 | $3,868.78 |