- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $10,471.29 / $12,882.50
| Professional | | $4,786.30 | $10,471.29 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Professional | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $11,481.54
| Facility | | $10,715.19 | $10,715.19 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $10,715.19 / $19,952.62
| Professional | | $1,230.27 | $10,715.19 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,174.90 / $6,456.54
| Facility | | $501.19 | $1,174.90 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,495.41 / $9,120.11
| Professional | | $3,311.31 | $5,495.41 | $9,120.11 |