- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,348.61 / $9,461.78 / $10,018.35
| Professional | | $5,348.61 | $9,461.78 | $10,018.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,732.10 / $5,732.10 / $5,732.10
| Professional | | $5,732.10 | $5,732.10 | $5,732.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $4,978.93 / $4,978.93
| Facility | | $4,978.93 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.47 / $4,978.93 / $14,737.50
| Professional | | $898.47 | $4,978.93 | $14,737.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.92 / $4,139.85 / $5,792.66
| Professional | | $2,395.92 | $4,139.85 | $5,792.66 |