- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,829.43 / $27,156.00 / $27,156.00
| Professional | | $7,829.43 | $27,156.00 | $27,156.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,553.03 / $10,177.20 / $10,177.20
| Facility | | $6,553.03 | $10,177.20 | $10,177.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,553.03 / $8,276.20 / $10,177.20
| Professional | | $6,553.03 | $8,276.20 | $10,177.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,055.16 / $9,692.58 / $10,177.20
| Facility | | $5,055.16 | $9,692.58 | $10,177.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,553.03 / $7,638.45 / $10,184.60
| Professional | | $6,553.03 | $7,638.45 | $10,184.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,088.42 / $4,523.51 / $7,174.26
| Professional | | $4,088.42 | $4,523.51 | $7,174.26 |