- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,468.91 / $4,391.01 / $4,948.24
| Professional | | $3,468.91 | $4,391.01 | $4,948.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.88 / $595.15 / $595.15
| Professional | | $505.88 | $595.15 | $595.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,649.60 / $5,470.13 / $5,470.13
| Professional | | $4,649.60 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,408.96 / $3,561.20 / $5,758.09
| Professional | | $2,408.96 | $3,561.20 | $5,758.09 |