- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,892.63 / $4,761.22 / $6,578.55
| Professional | | $3,892.63 | $4,761.22 | $6,578.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,106.30 / $5,106.30 / $5,106.30
| Professional | | $5,106.30 | $5,106.30 | $5,106.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.88 / $5,470.13 / $8,643.75
| Professional | | $585.88 | $5,470.13 | $8,643.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.59 / $2,763.88 / $5,160.18
| Professional | | $1,842.59 | $2,763.88 | $5,160.18 |