- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,622.91 / $4,750.89 / $4,916.63
| Professional | | $3,622.91 | $4,750.89 | $4,916.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,500.56 / $3,804.96 / $3,804.96
| Professional | | $3,500.56 | $3,804.96 | $3,804.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,350.72
| Facility | | $4,303.28 | $4,303.28 | $4,350.72 |
- 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 / $2,374.16 / $3,682.87
| Professional | | $1,473.15 | $2,374.16 | $3,682.87 |