- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,001.33 / $7,001.33 / $7,852.66
| Professional | | $7,001.33 | $7,001.33 | $7,852.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,807.68 / $3,807.68 / $4,184.68
| Professional | | $3,807.68 | $3,807.68 | $4,184.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.43 / $768.38 / $1,254.68
| Professional | | $123.43 | $768.38 | $1,254.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,147.96 / $12,655.20 / $18,168.36
| Facility | | $10,147.96 | $12,655.20 | $18,168.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.13 / $2,069.59 / $3,203.11
| Professional | | $1,757.13 | $2,069.59 | $3,203.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.21 / $1,394.64 / $2,243.26
| Professional | | $1,125.21 | $1,394.64 | $2,243.26 |