- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,011.32 / $4,935.70 / $5,640.39
| Professional | | $3,011.32 | $4,935.70 | $5,640.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,664.85 / $5,664.85 / $5,664.85
| Professional | | $5,664.85 | $5,664.85 | $5,664.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,106.14 / $5,106.14 / $5,106.14
| Facility | | $5,106.14 | $5,106.14 | $5,106.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.27 / $5,106.14 / $8,298.75
| Professional | | $560.27 | $5,106.14 | $8,298.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.64 / $2,440.62 / $5,615.57
| Professional | | $1,394.64 | $2,440.62 | $5,615.57 |