- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,777.46 / $14,862.10 / $14,862.10
| Professional | | $3,777.46 | $14,862.10 | $14,862.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,590.22 / $4,590.22 / $4,590.22
| Professional | | $4,590.22 | $4,590.22 | $4,590.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,266.66 / $4,889.30 / $5,203.58
| Facility | | $2,266.66 | $4,889.30 | $5,203.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,786.31 / $3,947.34 / $6,029.10
| Professional | | $2,786.31 | $3,947.34 | $6,029.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,927.31 / $4,889.29 / $7,991.98
| Professional | | $3,927.31 | $4,889.29 | $7,991.98 |