- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,391.01 / $5,017.82 / $6,505.46
| Professional | | $4,391.01 | $5,017.82 | $6,505.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,194.99 / $1,194.99 / $1,194.99
| Facility | | $1,194.99 | $1,194.99 | $1,194.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.88 / $731.88 / $731.88
| Professional | | $731.88 | $731.88 | $731.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,899.36 / $5,470.13 / $5,470.13
| Facility | | $3,899.36 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.88 / $5,470.13 / $5,470.13
| Professional | | $585.88 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.59 / $3,224.53 / $6,508.25
| Professional | | $1,842.59 | $3,224.53 | $6,508.25 |