- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,493.42 / $8,493.42 / $8,493.42
| Professional | | $8,493.42 | $8,493.42 | $8,493.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,503.37 / $7,503.37 / $7,503.37
| Facility | | $7,503.37 | $7,503.37 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $7,503.37 / $7,998.97
| Professional | | $5,477.46 | $7,503.37 | $7,998.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,034.15 / $3,034.15 / $3,034.15
| Facility | | $3,034.15 | $3,034.15 | $3,034.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,214.37 / $10,173.95 / $14,549.01
| Professional | | $9,214.37 | $10,173.95 | $14,549.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,034.15 / $3,034.15 / $7,503.37
| Facility | | $3,034.15 | $3,034.15 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $7,942.73 / $10,454.45
| Professional | | $5,477.46 | $7,942.73 | $10,454.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,687.91 / $4,838.89 / $9,274.54
| Professional | | $4,687.91 | $4,838.89 | $9,274.54 |