- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,786.30 / $5,754.40
| Professional | | $3,467.37 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,760.83
| Facility | | $6,606.93 | $6,606.93 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $6,606.93
| Professional | | $4,786.30 | $4,786.30 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,762.47 / $10,715.19
| Professional | | $7,244.36 | $7,762.47 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,466.84 / $6,309.57
| Facility | | $3,801.89 | $4,466.84 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,918.31 / $19,054.61
| Professional | | $3,162.28 | $6,918.31 | $19,054.61 |