- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,201.27 / $5,201.27 / $6,501.59
| Professional | | $5,201.27 | $5,201.27 | $6,501.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,014.09 / $10,014.09 / $10,014.09
| Facility | | $10,014.09 | $10,014.09 | $10,014.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,502.00 / $31,534.00 / $31,534.00
| Professional | | $4,502.00 | $31,534.00 | $31,534.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,911.83 / $3,773.73 / $4,892.39
| Facility | | $2,911.83 | $3,773.73 | $4,892.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,911.83 / $4,892.27 / $5,228.35
| Professional | | $2,911.83 | $4,892.27 | $5,228.35 |