- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,332.99 / $7,189.11 / $7,607.16
| Professional | | $5,332.99 | $7,189.11 | $7,607.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.73 / $914.98 / $914.98
| Professional | | $777.73 | $914.98 | $914.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,694.63 / $10,694.63 / $10,694.63
| Facility | | $10,694.63 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,090.44 / $10,694.63 / $10,694.63
| Professional | | $9,090.44 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,792.37 / $5,790.64 / $9,651.07
| Professional | | $3,792.37 | $5,790.64 | $9,651.07 |