- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,224.46 / $4,986.81 / $25,390.60
| Professional | | $4,224.46 | $4,986.81 | $25,390.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,684.57 / $7,684.57 / $7,684.57
| Facility | | $7,684.57 | $7,684.57 | $7,684.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,267.84 / $7,684.57 / $14,208.68
| Professional | | $4,267.84 | $7,684.57 | $14,208.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.07 / $6,265.15 / $9,548.21
| Facility | | $2,545.07 | $6,265.15 | $9,548.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,080.22 / $7,869.08 / $13,112.71
| Professional | | $5,080.22 | $7,869.08 | $13,112.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,821.64 / $8,558.54 / $10,877.09
| Professional | | $6,821.64 | $8,558.54 | $10,877.09 |