- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,135.84 / $12,679.28 / $13,057.77
| Professional | | $8,135.84 | $12,679.28 | $13,057.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,185.92 / $13,247.01 / $15,910.41
| Professional | | $8,185.92 | $13,247.01 | $15,910.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,275.38 / $13,275.38 / $13,275.38
| Facility | | $13,275.38 | $13,275.38 | $13,275.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.46 / $13,275.38 / $25,053.75
| Professional | | $1,527.46 | $13,275.38 | $25,053.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,110.55 / $2,110.55 / $2,110.55
| Professional | | $2,110.55 | $2,110.55 | $2,110.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.92 / $6,109.84 / $10,183.07
| Professional | | $4,783.92 | $6,109.84 | $10,183.07 |