- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $8,912.51
| Professional | | $7,079.46 | $7,079.46 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $10,232.93 / $10,232.93
| Facility | | $8,317.64 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $19,952.62
| Professional | | $19,952.62 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,715.35 / $5,370.32
| Facility | | $2,570.40 | $3,715.35 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $5,623.41
| Professional | | $3,388.44 | $3,388.44 | $5,623.41 |