- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,856.71 / $7,676.88 / $8,270.41
| Professional | | $5,856.71 | $7,676.88 | $8,270.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,509.57 / $10,336.49 / $10,336.49
| Professional | | $9,509.57 | $10,336.49 | $10,336.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,034.92 / $7,860.06 / $7,860.06
| Facility | | $7,034.92 | $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
- $2,388.98 / $3,855.00 / $5,951.07
| Professional | | $2,388.98 | $3,855.00 | $5,951.07 |