- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,071.33 / $9,071.33 / $9,071.33
| Professional | | $9,071.33 | $9,071.33 | $9,071.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.81 / $1,092.81 / $11,620.16
| Professional | | $1,092.81 | $1,092.81 | $11,620.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,546.22 / $7,327.59 / $18,592.25
| Facility | | $1,546.22 | $7,327.59 | $18,592.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.81 / $1,692.41 / $11,620.16
| Professional | | $1,092.81 | $1,692.41 | $11,620.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,926.28 / $6,507.39 / $6,567.65
| Professional | | $5,926.28 | $6,507.39 | $6,567.65 |