- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,930.45 / $3,810.74 / $4,996.17
| Professional | | $2,930.45 | $3,810.74 | $4,996.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,944.30 / $3,944.30 / $3,944.30
| Professional | | $3,944.30 | $3,944.30 | $3,944.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,124.25 / $4,124.25 / $4,124.25
| Facility | | $4,124.25 | $4,124.25 | $4,124.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.07 / $4,124.25 / $6,506.25
| Professional | | $441.07 | $4,124.25 | $6,506.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.44 / $2,235.12 / $3,985.96
| Professional | | $1,399.44 | $2,235.12 | $3,985.96 |