- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,585.78 / $7,943.28
| Professional | | $7,244.36 | $7,585.78 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,309.57 / $6,309.57
| Professional | | $6,025.60 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $8,511.38
| Facility | | $5,128.61 | $5,128.61 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $5,128.61 / $6,606.93
| Professional | | $912.01 | $5,128.61 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $11,220.18 / $11,220.18
| Professional | | $3,311.31 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,585.78 / $8,128.31
| Professional | | $7,244.36 | $7,585.78 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $851.14 / $5,623.41
| Facility | | $776.25 | $851.14 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,128.61 / $11,220.18
| Professional | | $3,311.31 | $5,128.61 | $11,220.18 |