- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,760.83 / $10,715.19
| Professional | | $5,128.61 | $6,760.83 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $8,912.51 / $8,912.51
| Professional | | $8,912.51 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $20,417.38
| Facility | | $8,128.31 | $8,128.31 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $14,454.40
| Professional | | $5,888.44 | $5,888.44 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $8,912.51 / $16,218.10
| Facility | | $7,943.28 | $8,912.51 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,025.60 / $8,912.51
| Professional | | $3,981.07 | $6,025.60 | $8,912.51 |