- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,674.05 / $7,473.57 / $7,734.28
| Professional | | $5,674.05 | $7,473.57 | $7,734.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,041.56 / $4,393.00 / $4,393.00
| Professional | | $4,041.56 | $4,393.00 | $4,393.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,818.66 / $3,818.66 / $6,797.73
| Facility | | $3,818.66 | $3,818.66 | $6,797.73 |
- 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
- $2,000.85 / $3,307.84 / $5,186.39
| Professional | | $2,000.85 | $3,307.84 | $5,186.39 |