- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Professional | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $7,943.28
| Facility | | $5,754.40 | $5,754.40 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,073.80 / $4,677.35
| Professional | | $2,754.23 | $4,073.80 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,388.44 / $4,677.35
| Professional | | $3,235.94 | $3,388.44 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |