- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,947.43 / $7,710.29 / $7,940.45
| Professional | | $4,947.43 | $7,710.29 | $7,940.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,977.84 / $6,910.64 / $8,055.53
| Professional | | $4,977.84 | $6,910.64 | $8,055.53 |
- 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
- $1,314.23 / $1,314.23 / $1,314.23
| Professional | | $1,314.23 | $1,314.23 | $1,314.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,518.51 / $3,715.40 / $6,192.33
| Professional | | $2,518.51 | $3,715.40 | $6,192.33 |