- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,540.10 / $6,998.33 / $6,998.33
| Professional | | $4,540.10 | $6,998.33 | $6,998.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,241.75 / $11,973.54 / $22,195.15
| Facility | | $9,241.75 | $11,973.54 | $22,195.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,011.71 / $6,011.71 / $7,801.07
| Professional | | $6,011.71 | $6,011.71 | $7,801.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,284.64 / $7,503.37 / $7,637.26
| Facility | | $7,284.64 | $7,503.37 | $7,637.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $5,477.46 / $7,503.37
| Professional | | $5,477.46 | $5,477.46 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,413.11 / $8,413.11 / $8,413.11
| Professional | | $8,413.11 | $8,413.11 | $8,413.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,850.80 / $6,998.33 / $6,998.33
| Professional | | $5,850.80 | $6,998.33 | $6,998.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,455.96 / $5,462.98 / $11,921.47
| Professional | | $3,455.96 | $5,462.98 | $11,921.47 |