- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,606.93 / $8,317.64
| Professional | | $4,466.84 | $6,606.93 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,585.78 / $7,585.78
| Facility | | $7,079.46 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $7,585.78 / $12,589.25
| Professional | | $812.83 | $7,585.78 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,071.52 / $5,754.40
| Facility | | $316.23 | $1,071.52 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,467.37 / $5,248.07
| Professional | | $2,238.72 | $3,467.37 | $5,248.07 |