- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,531.66 / $13,531.66 / $13,531.66
| Professional | | $13,531.66 | $13,531.66 | $13,531.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,638.55 / $6,895.54 / $7,585.09
| Professional | | $6,638.55 | $6,895.54 | $7,585.09 |
- 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 / $11,619.91
| Professional | | $9,876.92 | $9,876.92 | $11,619.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,156.60 / $8,156.60 / $13,531.66
| Professional | | $8,156.60 | $8,156.60 | $13,531.66 |