- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,606.93 / $11,481.54
| Professional | | $6,456.54 | $6,606.93 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $12,882.50
| Professional | | $12,882.50 | $12,882.50 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Facility | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Professional | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $870.96 / $5,888.44
| Facility | | $416.87 | $870.96 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,715.35 / $5,888.44
| Professional | | $3,162.28 | $3,715.35 | $5,888.44 |