- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,975.95 / $2,975.95 / $5,211.70
| Professional | | $2,975.95 | $2,975.95 | $5,211.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,812.40 / $5,812.40 / $5,812.40
| Professional | | $5,812.40 | $5,812.40 | $5,812.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $4,901.42
| Facility | | $3,655.97 | $3,655.97 | $4,901.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $3,655.97
| Professional | | $3,655.97 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.08 / $1,878.68 / $2,281.19
| Professional | | $1,426.08 | $1,878.68 | $2,281.19 |