- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,495.41 / $5,495.41
| Professional | | $5,248.07 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $660.69 / $660.69
| Professional | | $426.58 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,370.32
| Facility | | $5,248.07 | $5,248.07 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,248.07 / $5,370.32
| Professional | | $4,466.84 | $5,248.07 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $4,786.30
| Facility | | $707.95 | $707.95 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,265.80 / $7,079.46
| Professional | | $3,019.95 | $4,265.80 | $7,079.46 |