- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $4,466.84
| Professional | | $3,467.37 | $3,715.35 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $16,982.44
| Facility | | $16,982.44 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,848.93 / $15,848.93 / $15,848.93
| Professional | | $15,848.93 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Professional | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,715.35 / $4,168.69
| Professional | | $3,548.13 | $3,715.35 | $4,168.69 |