- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,681.96 / $12,817.34 / $13,104.50
| Professional | | $9,681.96 | $12,817.34 | $13,104.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,071.90 / $8,071.90 / $10,495.50
| Professional | | $8,071.90 | $8,071.90 | $10,495.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,102.62 / $10,102.62 / $10,102.62
| Facility | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,587.24 / $10,102.62 / $10,102.62
| Professional | | $8,587.24 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,284.08 / $7,284.08 / $7,284.08
| Professional | | $7,284.08 | $7,284.08 | $7,284.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,174.51 / $5,470.12 / $9,595.32
| Professional | | $4,174.51 | $5,470.12 | $9,595.32 |