- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,481.54 / $11,481.54 / $11,481.54
| Professional | | $11,481.54 | $11,481.54 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $8,317.64 / $16,218.10
| Facility | | $6,456.54 | $8,317.64 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,232.93 / $15,848.93 / $32,359.37
| Professional | | $10,232.93 | $15,848.93 | $32,359.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,943.28 / $21,379.62
| Facility | | $4,265.80 | $7,943.28 | $21,379.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $8,128.31 / $16,982.44
| Facility | | $3,715.35 | $8,128.31 | $16,982.44 |