- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,052.12 / $3,948.78 / $5,259.06
| Professional | | $3,052.12 | $3,948.78 | $5,259.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,705.60 / $4,705.60 / $4,705.60
| Professional | | $4,705.60 | $4,705.60 | $4,705.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,303.28
| Facility | | $4,303.28 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.38 / $4,303.28 / $6,776.25
| Professional | | $459.38 | $4,303.28 | $6,776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.15 / $2,209.71 / $4,279.79
| Professional | | $1,473.15 | $2,209.71 | $4,279.79 |