- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,817.74 / $7,857.15 / $8,319.33
| Professional | | $4,817.74 | $7,857.15 | $8,319.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,166.89 / $5,166.89 / $5,166.89
| Professional | | $5,166.89 | $5,166.89 | $5,166.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,608.68 / $7,608.68 / $7,608.68
| Facility | | $7,608.68 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.92 / $7,608.68 / $12,641.25
| Professional | | $816.92 | $7,608.68 | $12,641.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.21 / $3,493.60 / $5,315.75
| Professional | | $2,238.21 | $3,493.60 | $5,315.75 |