- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $8,912.51
| Professional | | $7,079.46 | $7,079.46 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,715.35 / $5,370.32
| Facility | | $2,570.40 | $3,715.35 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $5,888.44
| Professional | | $3,548.13 | $3,548.13 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,620.87 / $18,620.87 / $18,620.87
| Facility | | $18,620.87 | $18,620.87 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31,622.78 / $31,622.78 / $31,622.78
| Professional | | $31,622.78 | $31,622.78 | $31,622.78 |