- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,816.16 / $4,816.16 / $4,816.16
| Professional | | $4,816.16 | $4,816.16 | $4,816.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $5,109.46
| Facility | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.20 / $4,343.04 / $18,539.06
| Professional | | $904.20 | $4,343.04 | $18,539.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,895.26 / $5,105.63 / $8,094.29
| Professional | | $2,895.26 | $5,105.63 | $8,094.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,136.95 / $3,616.80 / $6,971.00
| Professional | | $3,136.95 | $3,616.80 | $6,971.00 |