- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,529.50 / $9,781.71 / $10,357.11
| Professional | | $5,529.50 | $9,781.71 | $10,357.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,584.40 / $6,584.40 / $6,584.40
| Professional | | $6,584.40 | $6,584.40 | $6,584.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,072.81 / $8,072.81 / $8,072.81
| Facility | | $8,072.81 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.85 / $8,072.81 / $15,236.25
| Professional | | $928.85 | $8,072.81 | $15,236.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,476.92 / $4,041.40 / $5,988.47
| Professional | | $2,476.92 | $4,041.40 | $5,988.47 |