- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,818.83 / $6,818.83 / $6,818.83
| Professional | | $6,818.83 | $6,818.83 | $6,818.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,662.05 / $5,035.01 / $5,035.50
| Professional | | $4,662.05 | $5,035.01 | $5,035.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,884.45 / $7,608.68 / $7,608.68
| Facility | | $6,884.45 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.92 / $7,056.55 / $7,608.68
| Professional | | $816.92 | $7,056.55 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,736.06 / $8,736.06 / $8,736.06
| Professional | | $8,736.06 | $8,736.06 | $8,736.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,817.74 / $4,817.74 / $6,818.83
| Professional | | $4,817.74 | $4,817.74 | $6,818.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,416.77 / $3,744.10 / $10,578.17
| Professional | | $2,416.77 | $3,744.10 | $10,578.17 |