- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,904.95 / $4,834.82 / $9,078.02
| Professional | | $2,904.95 | $4,834.82 | $9,078.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,608.68 / $7,608.68 / $7,608.68
| Facility | | $7,608.68 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,467.38 / $7,608.68 / $12,641.25
| Professional | | $6,467.38 | $7,608.68 | $12,641.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,766.16 / $6,766.16 / $6,766.16
| Professional | | $6,766.16 | $6,766.16 | $6,766.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,044.77 / $3,692.36 / $6,947.22
| Professional | | $3,044.77 | $3,692.36 | $6,947.22 |