- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,191.44 / $9,649.01 / $9,937.04
| Professional | | $6,191.44 | $9,649.01 | $9,937.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,229.56 / $8,071.90 / $10,081.04
| Professional | | $6,229.56 | $8,071.90 | $10,081.04 |
- 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
- $1,162.40 / $10,102.62 / $19,068.75
| Professional | | $1,162.40 | $10,102.62 | $19,068.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.69 / $1,644.69 / $1,644.69
| Professional | | $1,644.69 | $1,644.69 | $1,644.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,151.84 / $4,649.60 / $7,749.33
| Professional | | $3,151.84 | $4,649.60 | $7,749.33 |