- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,760.83 / $11,220.18
| Professional | | $5,011.87 | $6,760.83 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $8,709.64
| Facility | | $8,511.38 | $8,511.38 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,709.64 / $9,549.93 / $13,489.63
| Professional | | $8,709.64 | $9,549.93 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $10,964.78
| Professional | | $10,964.78 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,964.78 / $12,589.25
| Professional | | $6,606.93 | $10,964.78 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,585.78 / $8,709.64
| Facility | | $7,244.36 | $7,585.78 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $8,511.38 / $12,589.25
| Professional | | $6,456.54 | $8,511.38 | $12,589.25 |