- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,201.36 / $4,315.58 / $4,566.54
| Professional | | $3,201.36 | $4,315.58 | $4,566.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.87 / $549.26 / $549.26
| Professional | | $466.87 | $549.26 | $549.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,818.66 / $3,818.66 / $3,818.66
| Facility | | $3,818.66 | $3,818.66 | $3,818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,245.86 / $3,818.66 / $3,818.66
| Professional | | $3,245.86 | $3,818.66 | $3,818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,276.54 / $3,979.16 / $5,793.47
| Professional | | $2,276.54 | $3,979.16 | $5,793.47 |