- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,870.98 / $4,539.64 / $4,675.16
| Professional | | $3,870.98 | $4,539.64 | $4,675.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,742.92 / $4,742.92 / $5,723.24
| Professional | | $4,742.92 | $4,742.92 | $5,723.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $4,775.22
| Facility | | $4,775.22 | $4,775.22 | $4,775.22 |
- 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
- $777.40 / $777.40 / $777.40
| Professional | | $777.40 | $777.40 | $777.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,592.77 / $3,840.72 / $6,401.20
| Professional | | $2,592.77 | $3,840.72 | $6,401.20 |