- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,718.34 / $23,495.40 / $23,495.40
| Professional | | $4,718.34 | $23,495.40 | $23,495.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,356.47 / $7,356.47 / $7,356.47
| Facility | | $7,356.47 | $7,356.47 | $7,356.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,550.81 / $7,356.47 / $8,044.40
| Professional | | $4,550.81 | $7,356.47 | $8,044.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,617.64 / $7,882.55 / $8,433.12
| Facility | | $3,617.64 | $7,882.55 | $8,433.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,428.39 / $6,643.27 / $9,582.29
| Professional | | $4,428.39 | $6,643.27 | $9,582.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,487.86 / $8,006.32 / $12,852.86
| Professional | | $6,487.86 | $8,006.32 | $12,852.86 |