- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,397.34 / $7,778.95 / $8,236.53
| Professional | | $4,397.34 | $7,778.95 | $8,236.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,236.30 / $5,236.30 / $5,236.30
| Professional | | $5,236.30 | $5,236.30 | $5,236.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,818.66 / $3,818.66 / $3,818.66
| Facility | | $3,818.66 | $3,818.66 | $3,818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.67 / $3,818.66 / $12,116.25
| Professional | | $738.67 | $3,818.66 | $12,116.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.79 / $3,371.16 / $4,785.41
| Professional | | $1,969.79 | $3,371.16 | $4,785.41 |