- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,495.60 / $29,466.60 / $29,466.60
| Professional | | $8,495.60 | $29,466.60 | $29,466.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,261.93 / $11,026.65 / $11,026.65
| Facility | | $7,261.93 | $11,026.65 | $11,026.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,261.93 / $11,026.65 / $11,026.65
| Professional | | $7,261.93 | $11,026.65 | $11,026.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,155.71 / $10,501.57 / $11,026.65
| Facility | | $5,155.71 | $10,501.57 | $11,026.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,276.00 / $8,459.41 / $11,034.66
| Professional | | $8,276.00 | $8,459.41 | $11,034.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,169.75 / $4,613.50 / $7,316.97
| Professional | | $4,169.75 | $4,613.50 | $7,316.97 |