- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,726.18 / $5,117.85 / $5,296.39
| Professional | | $3,726.18 | $5,117.85 | $5,296.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,286.47 / $4,659.21 / $4,659.21
| Professional | | $4,286.47 | $4,659.21 | $4,659.21 |
- 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
- $1,610.64 / $2,514.96 / $3,967.33
| Professional | | $1,610.64 | $2,514.96 | $3,967.33 |