- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,275.62 / $8,275.62 / $8,275.62
| Professional | | $8,275.62 | $8,275.62 | $8,275.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Professional | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,834.14 / $11,834.14 / $11,834.14
| Facility | | $11,834.14 | $11,834.14 | $11,834.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,227.42 / $2,227.42 / $3,182.03
| Professional | | $2,227.42 | $2,227.42 | $3,182.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,582.12 / $8,582.12 / $13,486.20
| Facility | | $8,582.12 | $8,582.12 | $13,486.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,173.45 / $11,676.36 / $19,265.99
| Facility | | $8,173.45 | $11,676.36 | $19,265.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,227.42 / $3,182.03 / $5,210.58
| Professional | | $2,227.42 | $3,182.03 | $5,210.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $7,662.62 / $10,304.68
| Professional | | $5,108.41 | $7,662.62 | $10,304.68 |