- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,235.94 / $5,754.40
| Professional | | $3,019.95 | $3,235.94 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $11,481.54 / $11,481.54
| Professional | | $7,585.78 | $11,481.54 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,025.60 / $9,120.11
| Professional | | $3,890.45 | $6,025.60 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $18,197.01
| Facility | | $5,128.61 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,888.44 / $11,481.54
| Professional | | $3,388.44 | $5,888.44 | $11,481.54 |