- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,581.92 / $8,669.40 / $8,971.82
| Professional | | $6,581.92 | $8,669.40 | $8,971.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,688.18 / $5,095.85 / $5,095.85
| Professional | | $4,688.18 | $5,095.85 | $5,095.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $7,885.39
| Facility | | $7,447.14 | $7,447.14 | $7,885.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.86 / $7,447.14 / $14,055.00
| Professional | | $856.86 | $7,447.14 | $14,055.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.35 / $3,837.12 / $6,711.70
| Professional | | $2,323.35 | $3,837.12 | $6,711.70 |