- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,095.73 / $5,666.24 / $5,666.24
| Professional | | $2,095.73 | $5,666.24 | $5,666.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,298.10 / $7,298.10 / $7,298.10
| Professional | | $7,298.10 | $7,298.10 | $7,298.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,666.24 / $5,836.23 / $18,102.93
| Facility | | $5,666.24 | $5,836.23 | $18,102.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,791.19 / $2,821.79 / $2,854.96
| Professional | | $2,791.19 | $2,821.79 | $2,854.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,791.19 / $2,821.79 / $2,854.96
| Professional | | $2,791.19 | $2,821.79 | $2,854.96 |