- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,954.17 / $8,954.17 / $8,954.17
| Professional | | $8,954.17 | $8,954.17 | $8,954.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,302.44 / $8,302.44 / $8,302.44
| Facility | | $8,302.44 | $8,302.44 | $8,302.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,060.78 / $8,302.44 / $8,551.51
| Professional | | $6,060.78 | $8,302.44 | $8,551.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,419.40 / $3,419.40 / $3,419.40
| Facility | | $3,419.40 | $3,419.40 | $3,419.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,714.23 / $10,085.96 / $15,338.25
| Professional | | $9,714.23 | $10,085.96 | $15,338.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,419.40 / $3,419.40 / $8,302.44
| Facility | | $3,419.40 | $3,419.40 | $8,302.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,060.78 / $8,302.44 / $11,983.01
| Professional | | $6,060.78 | $8,302.44 | $11,983.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,101.39 / $5,101.39 / $9,777.67
| Professional | | $5,101.39 | $5,101.39 | $9,777.67 |