- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,450.85 / $5,834.33 / $6,103.04
| Professional | | $4,450.85 | $5,834.33 | $6,103.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,181.56 / $7,806.04 / $7,806.04
| Professional | | $7,181.56 | $7,806.04 | $7,806.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,346.20 / $5,587.01 / $5,587.01
| Facility | | $5,346.20 | $5,587.01 | $5,587.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.05 / $5,587.01 / $9,435.00
| Professional | | $615.05 | $5,587.01 | $9,435.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.50 / $2,902.53 / $4,522.72
| Professional | | $1,843.50 | $2,902.53 | $4,522.72 |