- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,454.71 / $2,454.71
| Professional | | $2,344.23 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,495.41 / $11,220.18
| Professional | | $4,365.16 | $5,495.41 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $5,011.87
| Professional | | $4,073.80 | $4,073.80 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $3,548.13
| Professional | | $1,479.11 | $1,479.11 | $3,548.13 |