- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,604.09 / $8,392.89 / $15,039.08
| Professional | | $4,604.09 | $8,392.89 | $15,039.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,155.72 / $11,155.72 / $11,155.72
| Facility | | $11,155.72 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,482.36 / $11,155.72 / $21,056.25
| Professional | | $9,482.36 | $11,155.72 | $21,056.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,080.72 / $12,080.72 / $12,080.72
| Professional | | $12,080.72 | $12,080.72 | $12,080.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,843.04 / $6,040.36 / $8,691.58
| Professional | | $4,843.04 | $6,040.36 | $8,691.58 |