- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,200.87 / $5,505.03 / $5,697.07
| Professional | | $4,200.87 | $5,505.03 | $5,697.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,656.00 / $5,060.87 / $5,060.87
| Professional | | $4,656.00 | $5,060.87 | $5,060.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $7,570.04
| Facility | | $4,775.22 | $4,775.22 | $7,570.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.41 / $4,775.22 / $9,011.25
| Professional | | $615.41 | $4,775.22 | $9,011.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,560.48 / $4,160.54 / $6,081.14
| Professional | | $2,560.48 | $4,160.54 | $6,081.14 |