- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,014.55 / $3,962.79 / $4,652.56
| Professional | | $3,014.55 | $3,962.79 | $4,652.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,419.74 / $4,804.06 / $4,804.06
| Professional | | $4,419.74 | $4,804.06 | $4,804.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $3,628.77
| Facility | | $2,673.00 | $2,673.00 | $3,628.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.53 / $2,673.00 / $5,756.25
| Professional | | $378.53 | $2,673.00 | $5,756.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.04 / $2,113.60 / $3,071.93
| Professional | | $1,486.04 | $2,113.60 | $3,071.93 |