- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $6,606.93
| Professional | | $2,454.71 | $3,715.35 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,760.83 / $20,892.96
| Facility | | $6,606.93 | $6,760.83 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,311.31 / $25,118.86
| Professional | | $3,235.94 | $3,311.31 | $25,118.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,118.86 / $25,118.86 / $30,199.52
| Facility | | $25,118.86 | $25,118.86 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,311.31 / $25,118.86
| Professional | | $2,951.21 | $3,311.31 | $25,118.86 |