- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,251.00 / $4,127.00 / $4,250.18
| Professional | | $2,251.00 | $4,127.00 | $4,250.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,311.79 / $4,311.79 / $5,146.92
| Professional | | $4,311.79 | $4,311.79 | $5,146.92 |
- 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
- $781.03 / $781.03 / $781.03
| Professional | | $781.03 | $781.03 | $781.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.96 / $2,127.19 / $4,265.78
| Professional | | $2,091.96 | $2,127.19 | $4,265.78 |