- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,035.10 / $8,919.32 / $8,919.32
| Professional | | $5,035.10 | $8,919.32 | $8,919.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,039.28 / $12,039.28 / $12,039.28
| Facility | | $12,039.28 | $12,039.28 | $12,039.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,534.80 / $8,404.62 / $16,715.33
| Professional | | $3,534.80 | $8,404.62 | $16,715.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,039.28 / $12,039.28 / $12,039.28
| Facility | | $12,039.28 | $12,039.28 | $12,039.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,534.80 / $8,404.62 / $16,715.33
| Professional | | $3,534.80 | $8,404.62 | $16,715.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,141.90 / $7,193.00 / $16,618.71
| Professional | | $3,141.90 | $7,193.00 | $16,618.71 |