- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,324.07 / $4,359.17 / $4,525.50
| Professional | | $3,324.07 | $4,359.17 | $4,525.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,881.06 / $5,305.50 / $5,305.50
| Professional | | $4,881.06 | $5,305.50 | $5,305.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.00 / $2,187.00 / $3,991.83
| Facility | | $2,187.00 | $2,187.00 | $3,991.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.04 / $2,187.00 / $6,363.75
| Professional | | $418.04 | $2,187.00 | $6,363.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.68 / $2,299.44 / $3,379.20
| Professional | | $1,351.68 | $2,299.44 | $3,379.20 |