- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,163.46 / $4,820.14 / $9,485.44
| Professional | | $3,163.46 | $4,820.14 | $9,485.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,860.06 / $7,860.06 / $7,860.06
| Facility | | $7,860.06 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,681.05 / $7,860.06 / $13,008.75
| Professional | | $6,681.05 | $7,860.06 | $13,008.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,128.16 / $7,128.16 / $7,128.16
| Professional | | $7,128.16 | $7,128.16 | $7,128.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,207.67 / $4,110.39 / $6,093.51
| Professional | | $3,207.67 | $4,110.39 | $6,093.51 |