- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,224.57 / $6,224.57 / $7,780.71
| Professional | | $6,224.57 | $6,224.57 | $7,780.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,026.38 / $8,026.38 / $8,026.38
| Facility | | $8,026.38 | $8,026.38 | $8,026.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,607.00 / $20,271.75 / $20,271.75
| Professional | | $4,607.00 | $20,271.75 | $20,271.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,456.91 / $3,085.88 / $5,245.97
| Facility | | $2,456.91 | $3,085.88 | $5,245.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.91 / $4,207.77 / $5,245.97
| Professional | | $2,456.91 | $4,207.77 | $5,245.97 |