- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,263.12 / $4,391.01 / $5,043.56
| Professional | | $4,263.12 | $4,391.01 | $5,043.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,289.28 / $5,116.64 / $5,116.64
| Professional | | $4,289.28 | $5,116.64 | $5,116.64 |
- 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
- $745.45 / $745.45 / $745.45
| Professional | | $745.45 | $745.45 | $745.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.17 / $2,763.88 / $4,694.89
| Professional | | $2,170.17 | $2,763.88 | $4,694.89 |