- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,228.53 / $32,008.70 / $32,008.70
| Professional | | $9,228.53 | $32,008.70 | $32,008.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,732.85 / $14,937.20 / $14,937.20
| Facility | | $8,732.85 | $14,937.20 | $14,937.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,732.85 / $12,147.07 / $14,937.20
| Professional | | $8,732.85 | $12,147.07 | $14,937.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,185.12 / $14,225.90 / $14,937.20
| Facility | | $6,185.12 | $14,225.90 | $14,937.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,732.85 / $11,211.03 / $14,948.04
| Professional | | $8,732.85 | $11,211.03 | $14,948.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,002.30 / $5,534.64 / $8,777.90
| Professional | | $5,002.30 | $5,534.64 | $8,777.90 |