- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.50 / $6,533.95 / $8,905.20
| Professional | | $3,184.50 | $6,533.95 | $8,905.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,300.15 / $5,300.15 / $5,406.15
| Facility | | $5,300.15 | $5,300.15 | $5,406.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,505.13 / $5,300.15 / $5,459.15
| Professional | | $4,505.13 | $5,300.15 | $5,459.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,171.44 / $6,705.73 / $7,796.79
| Professional | | $6,171.44 | $6,705.73 | $7,796.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,844.42 / $4,266.63 / $4,740.70
| Professional | | $2,844.42 | $4,266.63 | $4,740.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,910.33 / $4,155.72 / $5,690.31
| Professional | | $2,910.33 | $4,155.72 | $5,690.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,358.74 / $9,358.74 / $9,358.74
| Professional | | $9,358.74 | $9,358.74 | $9,358.74 |