- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $7,585.78 / $9,549.93
| Professional | | $3,548.13 | $7,585.78 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Professional | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $8,511.38
| Facility | | $5,128.61 | $5,128.61 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $5,128.61 / $14,791.08
| Professional | | $912.01 | $5,128.61 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $851.14 / $4,786.30
| Facility | | $371.54 | $851.14 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,073.80 / $6,918.31
| Professional | | $2,454.71 | $4,073.80 | $6,918.31 |