- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,949.60 / $3,733.79 / $4,207.39
| Professional | | $2,949.60 | $3,733.79 | $4,207.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.15 / $506.06 / $506.06
| Professional | | $430.15 | $506.06 | $506.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,587.01 / $5,587.01 / $5,587.01
| Facility | | $5,587.01 | $5,587.01 | $5,587.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,748.96 / $5,587.01 / $5,587.01
| Professional | | $4,748.96 | $5,587.01 | $5,587.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.34 / $2,966.76 / $5,329.34
| Professional | | $2,048.34 | $2,966.76 | $5,329.34 |