- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,443.91 / $25,818.80 / $25,818.80
| Professional | | $7,443.91 | $25,818.80 | $25,818.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,541.83 / $10,223.69 / $10,223.69
| Facility | | $6,541.83 | $10,223.69 | $10,223.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,541.83 / $8,314.00 / $10,223.69
| Professional | | $6,541.83 | $8,314.00 | $10,223.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,465.81 / $9,736.85 / $10,223.69
| Facility | | $4,465.81 | $9,736.85 | $10,223.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,541.83 / $7,673.33 / $10,231.10
| Professional | | $6,541.83 | $7,673.33 | $10,231.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,611.78 / $3,996.14 / $6,337.86
| Professional | | $3,611.78 | $3,996.14 | $6,337.86 |