- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,856.71 / $6,868.76 / $8,407.20
| Professional | | $5,856.71 | $6,868.76 | $8,407.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,316.73 / $1,316.73 / $1,316.73
| Facility | | $1,316.73 | $1,316.73 | $1,316.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.04 / $951.04 / $951.04
| Professional | | $951.04 | $951.04 | $951.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,451.66 / $7,860.06 / $7,860.06
| Facility | | $5,451.66 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.44 / $7,210.79 / $7,860.06
| Professional | | $814.44 | $7,210.79 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,376.05 / $3,906.72 / $6,814.57
| Professional | | $2,376.05 | $3,906.72 | $6,814.57 |