- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,244.36 / $7,244.36
| Professional | | $5,888.44 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Professional | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,302.69 / $12,302.69
| Facility | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,302.69 / $12,302.69
| Professional | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $10,471.29 / $25,703.96
| Facility | | $3,715.35 | $10,471.29 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $10,471.29 / $25,703.96
| Professional | | $3,715.35 | $10,471.29 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $12,302.69 / $18,620.87
| Facility | | $7,585.78 | $12,302.69 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $7,585.78 / $12,302.69
| Professional | | $79.43 | $7,585.78 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $3,715.35
| Professional | | $1,548.82 | $1,548.82 | $3,715.35 |