- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,901.53 / $9,090.37 / $9,407.48
| Professional | | $6,901.53 | $9,090.37 | $9,407.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,915.81 / $5,343.27 / $5,343.27
| Professional | | $4,915.81 | $5,343.27 | $5,343.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $4,978.93 / $8,268.27
| Facility | | $4,978.93 | $4,978.93 | $8,268.27 |
- 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
- $2,436.16 / $4,023.44 / $6,926.20
| Professional | | $2,436.16 | $4,023.44 | $6,926.20 |