- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,319.82 / $9,803.33 / $9,803.33
| Professional | | $7,319.82 | $9,803.33 | $9,803.33 |
- 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 / $10,694.63
| Professional | | $9,090.44 | $10,694.63 | $10,694.63 |
- 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
- $10,694.63 / $10,694.63 / $10,694.63
| Professional | | $10,694.63 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,860.43 / $6,245.06 / $9,651.07
| Professional | | $3,860.43 | $6,245.06 | $9,651.07 |