- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,165.95
| Professional | | $5,128.61 | $5,128.61 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $22,908.68 / $22,908.68
| Facility | | $3,388.44 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Professional | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $1,380.38 / $6,456.54
| Facility | | $109.65 | $1,380.38 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,258.93 / $2,398.83
| Professional | | $1,071.52 | $1,258.93 | $2,398.83 |