- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,731.09 / $7,511.24 / $7,914.38
| Professional | | $5,731.09 | $7,511.24 | $7,914.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,538.58 / $10,368.02 / $10,368.02
| Professional | | $9,538.58 | $10,368.02 | $10,368.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,884.45 / $7,608.68 / $7,608.68
| Facility | | $6,884.45 | $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 / $3,626.80 / $5,623.80
| Professional | | $2,238.21 | $3,626.80 | $5,623.80 |