- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,313.68 / $5,951.21 / $6,128.86
| Professional | | $4,313.68 | $5,951.21 | $6,128.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,340.16 / $4,803.00 / $6,217.68
| Professional | | $4,340.16 | $4,803.00 | $6,217.68 |
- 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
- $983.65 / $983.65 / $983.65
| Professional | | $983.65 | $983.65 | $983.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,195.94 / $3,357.32 / $4,499.04
| Professional | | $2,195.94 | $3,357.32 | $4,499.04 |