- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,413.79 / $8,045.93 / $14,417.38
| Professional | | $4,413.79 | $8,045.93 | $14,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,694.63 / $10,694.63 / $10,694.63
| Facility | | $10,694.63 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,090.44 / $10,694.63 / $20,182.50
| Professional | | $9,090.44 | $10,694.63 | $20,182.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,581.28 / $11,581.28 / $11,581.28
| Professional | | $11,581.28 | $11,581.28 | $11,581.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,642.85 / $5,790.64 / $10,655.89
| Professional | | $4,642.85 | $5,790.64 | $10,655.89 |