- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,169.49 / $7,600.61 / $13,619.33
| Professional | | $4,169.49 | $7,600.61 | $13,619.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,102.62 / $10,102.62 / $10,102.62
| Facility | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,587.24 / $10,102.62 / $19,068.75
| Professional | | $8,587.24 | $10,102.62 | $19,068.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,940.24 / $10,940.24 / $10,940.24
| Professional | | $10,940.24 | $10,940.24 | $10,940.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,385.84 / $5,470.12 / $7,612.24
| Professional | | $4,385.84 | $5,470.12 | $7,612.24 |