- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,713.62 / $5,006.10 / $5,297.22
| Professional | | $3,713.62 | $5,006.10 | $5,297.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.57 / $637.14 / $637.14
| Professional | | $541.57 | $637.14 | $637.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $7,447.14
| Facility | | $7,447.14 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,330.07 / $7,447.14 / $7,447.14
| Professional | | $6,330.07 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,640.77 / $4,032.28 / $8,400.59
| Professional | | $2,640.77 | $4,032.28 | $8,400.59 |