- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $13,489.63 / $13,489.63
| Professional | | $7,762.47 | $13,489.63 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,606.93 / $8,912.51
| Professional | | $5,623.41 | $6,606.93 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $11,748.98 / $12,022.64
| Professional | | $9,772.37 | $11,748.98 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $13,489.63 / $13,489.63
| Facility | | $1,230.27 | $13,489.63 | $13,489.63 |