- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,225.75 / $5,225.75 / $9,151.70
| Professional | | $5,225.75 | $5,225.75 | $9,151.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,206.50 / $10,206.50 / $10,206.50
| Professional | | $10,206.50 | $10,206.50 | $10,206.50 |
- 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
- $3,818.66 / $3,818.66 / $3,818.66
| Professional | | $3,818.66 | $3,818.66 | $3,818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,504.19 / $2,954.68 / $4,450.89
| Professional | | $2,504.19 | $2,954.68 | $4,450.89 |