- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,630.27 / $4,570.88
| Professional | | $2,570.40 | $2,630.27 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $5,248.07
| Facility | | $3,235.94 | $3,235.94 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Professional | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $1,949.84 / $4,073.80
| Facility | | $194.98 | $1,949.84 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,630.27 / $4,073.80
| Professional | | $2,187.76 | $2,630.27 | $4,073.80 |