- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,610.54 / $7,610.54 / $8,054.77
| Professional | | $7,610.54 | $7,610.54 | $8,054.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,239.16 / $6,738.29 / $8,112.40
| Professional | | $6,239.16 | $6,738.29 | $8,112.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $4,978.93 / $8,268.27
| Facility | | $4,978.93 | $4,978.93 | $8,268.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.47 / $4,978.93 / $5,609.52
| Professional | | $898.47 | $4,978.93 | $5,609.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,366.40 / $10,366.40 / $10,366.40
| Professional | | $10,366.40 | $10,366.40 | $10,366.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,344.64 / $7,610.54 / $8,054.77
| Professional | | $5,344.64 | $7,610.54 | $8,054.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.04 / $4,228.08 / $11,735.03
| Professional | | $2,769.04 | $4,228.08 | $11,735.03 |