- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,779.83 / $7,612.89 / $7,878.46
| Professional | | $5,779.83 | $7,612.89 | $7,878.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,116.81 / $4,474.79 / $4,474.79
| Professional | | $4,116.81 | $4,474.79 | $4,474.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,539.60 / $6,539.60 / $6,924.42
| Facility | | $6,539.60 | $6,539.60 | $6,924.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.44 / $6,539.60 / $12,341.25
| Professional | | $752.44 | $6,539.60 | $12,341.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,040.16 / $3,369.48 / $5,893.70
| Professional | | $2,040.16 | $3,369.48 | $5,893.70 |