- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $8,511.38
| Professional | | $6,760.83 | $6,760.83 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $8,128.31
| Professional | | $151.36 | $151.36 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $5,248.07 / $12,589.25
| Facility | | $54.95 | $5,248.07 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,623.41 / $22,908.68
| Professional | | $4,168.69 | $5,623.41 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Professional | | $6,309.57 | $6,309.57 | $6,309.57 |