- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $4,168.69
| Professional | | $3,467.37 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $26,302.68 / $26,302.68
| Facility | | $8,511.38 | $26,302.68 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,122.02 / $2,951.21
| Facility | | $776.25 | $1,122.02 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,071.52 / $1,288.25
| Professional | | $870.96 | $1,071.52 | $1,288.25 |