- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,867.87 / $7,867.87 / $7,867.87
| Professional | | $7,867.87 | $7,867.87 | $7,867.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,450.06 / $8,386.70 / $8,386.70
| Professional | | $6,450.06 | $8,386.70 | $8,386.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,072.81 / $8,072.81 / $8,547.89
| Facility | | $8,072.81 | $8,072.81 | $8,547.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.85 / $8,072.81 / $8,072.81
| Professional | | $928.85 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,716.92 / $10,716.92 / $10,716.92
| Professional | | $10,716.92 | $10,716.92 | $10,716.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,525.35 / $5,525.35 / $7,867.87
| Professional | | $5,525.35 | $5,525.35 | $7,867.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.03 / $4,371.04 / $8,761.53
| Professional | | $2,914.03 | $4,371.04 | $8,761.53 |