- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $7,244.36 / $8,912.51
| Professional | | $3,311.31 | $7,244.36 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $8,128.31
| Facility | | $7,413.10 | $7,413.10 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $7,413.10 / $14,125.38
| Professional | | $851.14 | $7,413.10 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $812.83 / $4,570.88
| Facility | | $346.74 | $812.83 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,801.89 / $6,760.83
| Professional | | $2,344.23 | $3,801.89 | $6,760.83 |