- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,321.58 / $11,150.46 / $11,892.80
| Professional | | $5,321.58 | $11,150.46 | $11,892.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,198.91 / $14,351.66 / $14,351.66
| Professional | | $12,198.91 | $14,351.66 | $14,351.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,551.49 / $7,551.49 / $7,551.49
| Facility | | $7,551.49 | $7,551.49 | $7,551.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,418.77 / $7,551.49 / $7,551.49
| Professional | | $6,418.77 | $7,551.49 | $7,551.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,449.38 / $9,191.68 / $14,173.49
| Professional | | $5,449.38 | $9,191.68 | $14,173.49 |