- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,733.79 / $4,450.85 / $6,460.92
| Professional | | $3,733.79 | $4,450.85 | $6,460.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,342.10 / $4,342.10 / $4,342.10
| Professional | | $4,342.10 | $4,342.10 | $4,342.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,587.01 / $5,587.01 / $6,653.09
| Facility | | $5,587.01 | $5,587.01 | $6,653.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.05 / $5,587.01 / $9,435.00
| Professional | | $615.05 | $5,587.01 | $9,435.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.59 / $2,713.64 / $4,387.85
| Professional | | $1,658.59 | $2,713.64 | $4,387.85 |