- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,121.26 / $8,425.81 / $8,628.84
| Professional | | $8,121.26 | $8,425.81 | $8,628.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $470.59 / $470.59 / $1,033.56
| Facility | | $470.59 | $470.59 | $1,033.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.59 / $8,628.84 / $8,628.84
| Professional | | $470.59 | $8,628.84 | $8,628.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $386.03 / $673.23 / $10,151.58
| Facility | | $386.03 | $673.23 | $10,151.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.34 / $9,770.53 / $10,574.58
| Professional | | $434.34 | $9,770.53 | $10,574.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,459.66 / $8,459.66 / $8,459.66
| Professional | | $8,459.66 | $8,459.66 | $8,459.66 |