- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,625.04 / $3,733.79 / $4,885.41
| Professional | | $3,625.04 | $3,733.79 | $4,885.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,647.28 / $3,917.60 / $4,956.21
| Professional | | $3,647.28 | $3,917.60 | $4,956.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,587.01 / $5,587.01 / $5,587.01
| Facility | | $5,587.01 | $5,587.01 | $5,587.01 |
- 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
- $767.35 / $767.35 / $767.35
| Professional | | $767.35 | $767.35 | $767.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.36 / $2,487.88 / $4,146.47
| Professional | | $1,845.36 | $2,487.88 | $4,146.47 |