- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,893.95 / $4,929.16 / $5,554.45
| Professional | | $3,893.95 | $4,929.16 | $5,554.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.87 / $668.08 / $668.08
| Professional | | $567.87 | $668.08 | $668.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,300.15 / $5,300.15 / $5,406.15
| Facility | | $5,300.15 | $5,300.15 | $5,406.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,505.13 / $5,300.15 / $5,406.15
| Professional | | $4,505.13 | $5,300.15 | $5,406.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.04 / $4,228.08 / $7,046.80
| Professional | | $2,769.04 | $4,228.08 | $7,046.80 |