- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $6,025.60 / $11,220.18
| Facility | | $3,090.30 | $6,025.60 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,220.18 / $11,220.18
| Professional | | $7,413.10 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $11,481.54 / $23,988.33
| Facility | | $6,025.60 | $11,481.54 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,290.87
| Professional | | $2,238.72 | $2,238.72 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,754.40 / $12,302.69
| Facility | | $2,630.27 | $5,754.40 | $12,302.69 |