- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,976.53 / $9,496.20 / $10,054.79
| Professional | | $5,976.53 | $9,496.20 | $10,054.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,736.40 / $7,736.40 / $7,736.40
| Professional | | $7,736.40 | $7,736.40 | $7,736.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,391.94 / $8,391.94 / $8,391.94
| Facility | | $8,391.94 | $8,391.94 | $8,391.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.52 / $8,391.94 / $16,584.38
| Professional | | $899.52 | $8,391.94 | $16,584.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,816.19 / $4,224.28 / $7,818.06
| Professional | | $2,816.19 | $4,224.28 | $7,818.06 |