- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,344.64 / $6,901.53 / $10,018.35
| Professional | | $5,344.64 | $6,901.53 | $10,018.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,707.82 / $6,707.82 / $6,707.82
| Professional | | $6,707.82 | $6,707.82 | $6,707.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,300.15 / $5,300.15 / $5,406.15
| Facility | | $5,300.15 | $5,300.15 | $5,406.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.47 / $5,300.15 / $14,737.50
| Professional | | $898.47 | $5,300.15 | $14,737.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.92 / $4,155.43 / $5,792.66
| Professional | | $2,395.92 | $4,155.43 | $5,792.66 |