- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.42 / $7,026.45 / $7,026.45
| Professional | | $5,246.42 | $7,026.45 | $7,026.45 |
- 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 / $7,860.06
| Professional | | $6,681.05 | $7,860.06 | $7,860.06 |
- 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
- $7,860.06 / $7,860.06 / $7,860.06
| Professional | | $7,860.06 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.18 / $3,564.08 / $6,686.47
| Professional | | $947.18 | $3,564.08 | $6,686.47 |