- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,734.94 / $6,734.94 / $8,418.67
| Professional | | $6,734.94 | $6,734.94 | $8,418.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,597.18 / $8,597.18 / $8,597.18
| Facility | | $8,597.18 | $8,597.18 | $8,597.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,600.00 / $12,600.00 / $12,600.00
| Professional | | $12,600.00 | $12,600.00 | $12,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,028.00 / $4,028.00 / $6,367.49
| Facility | | $4,028.00 | $4,028.00 | $6,367.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,028.00 / $5,832.00 / $7,250.40
| Professional | | $4,028.00 | $5,832.00 | $7,250.40 |