- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,872.65 / $10,872.65 / $11,505.78
| Professional | | $10,872.65 | $10,872.65 | $11,505.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.83 / $11,589.60 / $13,370.01
| Professional | | $9,549.83 | $11,589.60 | $13,370.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,155.72 / $11,155.72 / $11,812.31
| Facility | | $11,155.72 | $11,155.72 | $11,812.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.58 / $11,155.72 / $11,155.72
| Professional | | $1,283.58 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,809.75 / $14,809.75 / $14,809.75
| Professional | | $14,809.75 | $14,809.75 | $14,809.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,635.49 / $10,872.65 / $11,505.78
| Professional | | $7,635.49 | $10,872.65 | $11,505.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,026.91 / $6,040.36 / $14,809.75
| Professional | | $4,026.91 | $6,040.36 | $14,809.75 |