- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,250.79 / $5,250.79 / $9,195.54
| Professional | | $5,250.79 | $5,250.79 | $9,195.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,255.44 / $10,255.44 / $10,255.44
| Facility | | $10,255.44 | $10,255.44 | $10,255.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,255.44 / $10,255.44 / $10,255.44
| Professional | | $10,255.44 | $10,255.44 | $10,255.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,261.93 / $7,261.93 / $10,905.82
| Facility | | $7,261.93 | $7,261.93 | $10,905.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,301.21 / $5,301.21 / $9,180.69
| Professional | | $5,301.21 | $5,301.21 | $9,180.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,169.75 / $4,613.50 / $7,109.25
| Professional | | $4,169.75 | $4,613.50 | $7,109.25 |