- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,981.07 / $4,786.30
| Professional | | $3,890.45 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $5,623.41
| Professional | | $4,786.30 | $4,786.30 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $5,623.41
| Facility | | $4,786.30 | $4,786.30 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $5,623.41
| Professional | | $4,786.30 | $4,786.30 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,786.30 / $7,244.36
| Facility | | $2,570.40 | $4,786.30 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $4,786.30 / $5,623.41
| Professional | | $79.43 | $4,786.30 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Professional | | $5,623.41 | $5,623.41 | $5,623.41 |