- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,918.31
| Professional | | $5,128.61 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,495.41 / $6,760.83
| Professional | | $4,365.16 | $5,495.41 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $7,079.46
| Professional | | $5,623.41 | $5,623.41 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,606.93
| Facility | | $5,128.61 | $5,128.61 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $1,949.84 / $3,467.37
| Professional | | $30.20 | $1,949.84 | $3,467.37 |