- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,470.60 / $7,874.59 / $10,569.00
| Professional | | $5,470.60 | $7,874.59 | $10,569.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,600.00 / $7,600.00 / $9,488.16
| Professional | | $7,600.00 | $7,600.00 | $9,488.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,100.47 / $7,100.47 / $7,100.47
| Facility | | $7,100.47 | $7,100.47 | $7,100.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,035.40 / $7,100.47 / $7,100.47
| Professional | | $6,035.40 | $7,100.47 | $7,100.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,197.07 / $7,874.59 / $10,569.00
| Facility | | $5,197.07 | $7,874.59 | $10,569.00 |