- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,441.81 / $4,513.18 / $5,142.93
| Professional | | $3,441.81 | $4,513.18 | $5,142.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,361.08 / $3,653.35 / $3,653.35
| Professional | | $3,361.08 | $3,653.35 | $3,653.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,124.25 / $4,124.25 / $4,133.35
| Facility | | $4,124.25 | $4,124.25 | $4,133.35 |
- 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
- $1,674.66 / $2,449.02 / $3,498.60
| Professional | | $1,674.66 | $2,449.02 | $3,498.60 |