- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,456.54 / $11,220.18
| Professional | | $6,309.57 | $6,456.54 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,589.25 / $12,589.25 / $12,589.25
| Professional | | $12,589.25 | $12,589.25 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $851.14 / $5,623.41
| Facility | | $407.38 | $851.14 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,630.78 / $5,754.40
| Professional | | $3,090.30 | $3,630.78 | $5,754.40 |