- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.10 / $4,802.52 / $4,802.52
| Professional | | $2,711.10 | $4,802.52 | $4,802.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,482.43 / $6,482.43 / $6,482.43
| Facility | | $6,482.43 | $6,482.43 | $6,482.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,999.46 / $4,999.46 / $4,999.46
| Professional | | $4,999.46 | $4,999.46 | $4,999.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,482.43 / $6,482.43 / $6,482.43
| Facility | | $6,482.43 | $6,482.43 | $6,482.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,517.44 / $2,517.44 / $4,999.46
| Professional | | $2,517.44 | $2,517.44 | $4,999.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.73 / $3,873.00 / $17,428.50
| Professional | | $1,691.73 | $3,873.00 | $17,428.50 |