- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,760.83
| Professional | | $6,456.54 | $6,456.54 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $10,471.29
| Professional | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Facility | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Professional | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,265.80 / $4,677.35
| Professional | | $2,818.38 | $4,265.80 | $4,677.35 |