- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,822.38 / $5,849.94 / $7,312.43
| Professional | | $3,822.38 | $5,849.94 | $7,312.43 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $469.76 / $4,697.60 / $8,377.54
| Facility | | $469.76 | $4,697.60 | $8,377.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,391.34 / $3,965.32 / $6,824.40
| Professional | | $2,391.34 | $3,965.32 | $6,824.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,970.07 / $3,812.40 / $6,824.40
| Professional | | $2,970.07 | $3,812.40 | $6,824.40 |