- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,318.25 / $5,318.25 / $9,400.79
| Professional | | $5,318.25 | $5,318.25 | $9,400.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,326.70 / $10,326.70 / $10,326.70
| Professional | | $10,326.70 | $10,326.70 | $10,326.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,608.68 / $7,608.68 / $7,608.68
| Facility | | $7,608.68 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,608.68 / $7,608.68 / $7,608.68
| Professional | | $7,608.68 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,745.67 / $3,244.88 / $4,879.89
| Professional | | $2,745.67 | $3,244.88 | $4,879.89 |