- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,036.26 / $5,036.26 / $5,036.26
| Professional | | $5,036.26 | $5,036.26 | $5,036.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,351.02 / $6,295.32 / $6,295.32
| Professional | | $5,351.02 | $6,295.32 | $6,295.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Professional | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,710.60 / $9,710.60 / $10,681.66
| Facility | | $9,710.60 | $9,710.60 | $10,681.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,246.10 / $5,246.10
| Professional | | $5,246.10 | $5,246.10 | $5,246.10 |