- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,011.15 / $7,917.59 / $8,193.79
| Professional | | $6,011.15 | $7,917.59 | $8,193.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,281.74 / $4,654.07 / $4,654.07
| Professional | | $4,281.74 | $4,654.07 | $4,654.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $7,201.58
| Facility | | $3,704.40 | $3,704.40 | $7,201.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $3,704.40 / $12,836.25
| Professional | | $782.55 | $3,704.40 | $12,836.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.77 / $3,504.40 / $6,129.80
| Professional | | $2,119.77 | $3,504.40 | $6,129.80 |