- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,510.05 / $5,568.30 / $6,960.38
| Professional | | $3,510.05 | $5,568.30 | $6,960.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,884.45 / $7,608.68 / $7,608.68
| Facility | | $6,884.45 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.92 / $7,608.68 / $12,641.25
| Professional | | $816.92 | $7,608.68 | $12,641.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $431.37 / $4,313.68 / $7,692.94
| Facility | | $431.37 | $4,313.68 | $7,692.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.21 / $3,655.47 / $5,623.80
| Professional | | $2,238.21 | $3,655.47 | $5,623.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.21 / $3,641.36 / $5,623.80
| Professional | | $2,238.21 | $3,641.36 | $5,623.80 |