- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,525.35 / $7,400.03 / $7,400.03
| Professional | | $5,525.35 | $7,400.03 | $7,400.03 |
- 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 / $8,072.81
| Professional | | $6,861.89 | $8,072.81 | $8,072.81 |
- 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
- $8,072.81 / $8,072.81 / $8,072.81
| Professional | | $8,072.81 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.03 / $4,714.02 / $7,285.07
| Professional | | $2,914.03 | $4,714.02 | $7,285.07 |