- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.94 / $1,747.13 / $1,807.62
| Professional | | $1,494.94 | $1,747.13 | $1,807.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,123.00 / $5,123.00 / $5,123.00
| Professional | | $5,123.00 | $5,123.00 | $5,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,510.77 / $7,510.77 / $7,510.77
| Facility | | $7,510.77 | $7,510.77 | $7,510.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,399.68 / $4,589.57 / $6,072.50
| Professional | | $3,399.68 | $4,589.57 | $6,072.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,660.28 / $2,495.94 / $3,930.25
| Professional | | $1,660.28 | $2,495.94 | $3,930.25 |