- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,370.32 / $9,332.54
| Professional | | $5,248.07 | $5,370.32 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $10,471.29
| Professional | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Professional | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $707.95 / $4,677.35
| Facility | | $338.84 | $707.95 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,019.95 / $4,786.30
| Professional | | $2,570.40 | $3,019.95 | $4,786.30 |