- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,135.61 / $18,620.87 / $18,620.87
| Professional | | $15,135.61 | $18,620.87 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,801.89
| Professional | | $2,691.53 | $2,691.53 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,877.62 / $21,877.62 / $26,915.35
| Facility | | $21,877.62 | $21,877.62 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,801.89 / $3,801.89
| Professional | | $2,691.53 | $3,801.89 | $3,801.89 |