- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,310.19 / $4,380.72 / $4,380.72
| Professional | | $3,310.19 | $4,380.72 | $4,380.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,411.53 / $5,411.53 / $5,411.53
| Facility | | $5,411.53 | $5,411.53 | $5,411.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.37 / $5,411.53 / $5,411.53
| Professional | | $927.37 | $5,411.53 | $5,411.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.75 / $2,714.75 / $5,411.53
| Facility | | $2,714.75 | $2,714.75 | $5,411.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,983.64 / $4,475.92 / $6,456.10
| Professional | | $2,983.64 | $4,475.92 | $6,456.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,855.67 / $5,013.72 / $5,734.61
| Professional | | $2,855.67 | $5,013.72 | $5,734.61 |