- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,261.02 / $4,395.99 / $4,651.63
| Professional | | $3,261.02 | $4,395.99 | $4,651.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,742.20 / $5,742.20 / $5,742.20
| Professional | | $5,742.20 | $5,742.20 | $5,742.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,539.60 / $6,539.60 / $6,539.60
| Facility | | $6,539.60 | $6,539.60 | $6,539.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,558.66 / $6,539.60 / $6,539.60
| Professional | | $5,558.66 | $6,539.60 | $6,539.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,318.94 / $3,540.88 / $5,901.47
| Professional | | $2,318.94 | $3,540.88 | $5,901.47 |