- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,531.89 / $5,942.34 / $6,149.63
| Professional | | $4,531.89 | $5,942.34 | $6,149.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,464.64 / $4,852.88 / $4,852.88
| Professional | | $4,464.64 | $4,852.88 | $4,852.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,442.61 / $5,470.13 / $5,470.13
| Facility | | $5,442.61 | $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
- $2,168.07 / $2,960.13 / $4,606.47
| Professional | | $2,168.07 | $2,960.13 | $4,606.47 |