- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,511.89 / $2,818.38
| Professional | | $1,513.56 | $2,511.89 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,677.35 / $9,549.93
| Professional | | $3,715.35 | $4,677.35 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Facility | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $3,019.95
| Professional | | $1,258.93 | $1,258.93 | $3,019.95 |