- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,982.43 / $6,562.57 / $6,791.50
| Professional | | $4,982.43 | $6,562.57 | $6,791.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.89 / $3,857.49 / $3,857.49
| Professional | | $3,548.89 | $3,857.49 | $3,857.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,087.00 / $3,087.00 / $5,969.12
| Facility | | $3,087.00 | $3,087.00 | $5,969.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.63 / $3,087.00 / $10,638.75
| Professional | | $648.63 | $3,087.00 | $10,638.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.01 / $2,873.24 / $4,107.99
| Professional | | $1,757.01 | $2,873.24 | $4,107.99 |