- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,331.71 / $6,073.41 / $10,882.92
| Professional | | $3,331.71 | $6,073.41 | $10,882.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,072.81 / $8,072.81 / $8,072.81
| Facility | | $8,072.81 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,861.89 / $8,072.81 / $15,236.25
| Professional | | $6,861.89 | $8,072.81 | $15,236.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,742.08 / $8,742.08 / $8,742.08
| Professional | | $8,742.08 | $8,742.08 | $8,742.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,504.61 / $4,371.04 / $5,420.61
| Professional | | $3,504.61 | $4,371.04 | $5,420.61 |