- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,491.85 / $5,491.85 / $9,617.70
| Professional | | $5,491.85 | $5,491.85 | $9,617.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,726.27 / $10,726.27 / $10,726.27
| Facility | | $10,726.27 | $10,726.27 | $10,726.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,726.27 / $10,726.27 / $10,726.27
| Professional | | $10,726.27 | $10,726.27 | $10,726.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,503.37 / $7,503.37 / $11,120.11
| Facility | | $7,503.37 | $7,503.37 | $11,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $5,477.46 / $7,503.37
| Professional | | $5,477.46 | $5,477.46 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,247.81 / $6,266.48 / $7,242.34
| Professional | | $4,247.81 | $6,266.48 | $7,242.34 |