- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,165.95 / $8,912.51
| Professional | | $5,011.87 | $6,165.95 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,022.64 / $12,022.64
| Facility | | $12,022.64 | $12,022.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $7,943.28 / $11,220.18
| Professional | | $3,548.13 | $7,943.28 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Facility | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Professional | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $7,244.36 / $16,595.87
| Professional | | $3,162.28 | $7,244.36 | $16,595.87 |