- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $9,549.93 / $12,302.69
| Professional | | $7,244.36 | $9,549.93 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Facility | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $8,317.64 / $8,317.64
| Professional | | $7,079.46 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $6,165.95
| Facility | | $741.31 | $741.31 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $8,511.38
| Professional | | $2,818.38 | $5,128.61 | $8,511.38 |