- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,836.80 / $10,654.88 / $10,972.93
| Professional | | $6,836.80 | $10,654.88 | $10,972.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,878.88 / $10,606.94 / $11,131.96
| Professional | | $6,878.88 | $10,606.94 | $11,131.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,155.72 / $11,155.72 / $11,155.72
| Facility | | $11,155.72 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.58 / $11,155.72 / $21,056.25
| Professional | | $1,283.58 | $11,155.72 | $21,056.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,816.14 / $1,816.14 / $1,816.14
| Professional | | $1,816.14 | $1,816.14 | $1,816.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,480.39 / $5,134.32 / $8,557.20
| Professional | | $3,480.39 | $5,134.32 | $8,557.20 |