- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,736.28 / $6,384.70 / $11,773.76
| Professional | | $4,736.28 | $6,384.70 | $11,773.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,125.98 / $15,871.50 / $18,352.53
| Facility | | $8,125.98 | $15,871.50 | $18,352.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,907.08 / $8,125.98 / $8,125.98
| Professional | | $6,907.08 | $8,125.98 | $8,125.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,777.03 / $10,777.03 / $10,777.03
| Professional | | $10,777.03 | $10,777.03 | $10,777.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,052.04 / $7,591.96 / $11,377.08
| Professional | | $5,052.04 | $7,591.96 | $11,377.08 |