- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,112.79 / $8,029.36 / $8,501.67
| Professional | | $5,112.79 | $8,029.36 | $8,501.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,251.90 / $6,251.90 / $6,251.90
| Professional | | $6,251.90 | $6,251.90 | $6,251.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,860.06 / $7,860.06 / $7,860.06
| Facility | | $7,860.06 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.44 / $7,860.06 / $13,008.75
| Professional | | $814.44 | $7,860.06 | $13,008.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,376.05 / $3,570.64 / $5,686.09
| Professional | | $2,376.05 | $3,570.64 | $5,686.09 |