- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,748.77 / $13,531.66 / $13,531.66
| Professional | | $7,748.77 | $13,531.66 | $13,531.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,225.50 / $15,225.50 / $15,225.50
| Professional | | $15,225.50 | $15,225.50 | $15,225.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,619.91 / $11,619.91 / $11,619.91
| Facility | | $11,619.91 | $11,619.91 | $11,619.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,876.92 / $9,876.92 / $9,876.92
| Professional | | $9,876.92 | $9,876.92 | $9,876.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,638.55 / $7,459.35 / $7,459.35
| Professional | | $6,638.55 | $7,459.35 | $7,459.35 |