- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,128.61 / $7,079.46
| Professional | | $2,691.53 | $5,128.61 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $11,748.98 / $23,988.33
| Professional | | $9,549.93 | $11,748.98 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,135.61 / $15,135.61 / $15,135.61
| Facility | | $15,135.61 | $15,135.61 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $7,585.78
| Professional | | $3,162.28 | $3,162.28 | $7,585.78 |