- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,323.15 / $5,323.15 / $9,322.29
| Professional | | $5,323.15 | $5,323.15 | $9,322.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,396.79 / $10,396.79 / $10,396.79
| Professional | | $10,396.79 | $10,396.79 | $10,396.79 |
- 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
- $6,539.60 / $6,539.60 / $6,539.60
| Professional | | $6,539.60 | $6,539.60 | $6,539.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,550.83 / $3,009.76 / $4,533.70
| Professional | | $2,550.83 | $3,009.76 | $4,533.70 |