- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,914.66 / $9,260.70 / $9,260.70
| Professional | | $6,914.66 | $9,260.70 | $9,260.70 |
- 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 / $10,102.62
| Professional | | $8,587.24 | $10,102.62 | $10,102.62 |
- 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
- $10,102.62 / $10,102.62 / $10,102.62
| Professional | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,646.75 / $5,899.42 / $9,116.87
| Professional | | $3,646.75 | $5,899.42 | $9,116.87 |