- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,760.83 / $10,232.93
| Professional | | $4,466.84 | $6,760.83 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,606.93 / $6,606.93
| Professional | | $5,495.41 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $602.56 / $3,981.07
| Facility | | $524.81 | $602.56 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $5,888.44
| Professional | | $2,344.23 | $3,162.28 | $5,888.44 |