- 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
- $13,803.84 / $26,302.68 / $26,302.68
| Facility | | $13,803.84 | $26,302.68 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Professional | | $6,456.54 | $6,456.54 | $6,456.54 |
- 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
- $891.25 / $1,096.48 / $1,318.26
| Professional | | $891.25 | $1,096.48 | $1,318.26 |