- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,562.52 / $7,326.68 / $7,582.27
| Professional | | $5,562.52 | $7,326.68 | $7,582.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,962.14 / $4,306.67 / $4,306.67
| Professional | | $3,962.14 | $4,306.67 | $4,306.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.57 / $4,321.80 / $6,664.07
| Facility | | $775.57 | $4,321.80 | $6,664.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.15 / $3,673.53 / $14,850.00
| Professional | | $724.15 | $3,673.53 | $14,850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.55 / $3,242.84 / $5,561.30
| Professional | | $1,961.55 | $3,242.84 | $5,561.30 |