- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,391.63 / $4,572.04 / $4,837.91
| Professional | | $3,391.63 | $4,572.04 | $4,837.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,972.04 / $5,972.04 / $5,972.04
| Professional | | $5,972.04 | $5,972.04 | $5,972.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,704.40
| Facility | | $3,704.40 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,148.74 / $3,704.40 / $3,704.40
| Professional | | $3,148.74 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.84 / $3,682.60 / $6,137.67
| Professional | | $2,411.84 | $3,682.60 | $6,137.67 |