- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,606.93 / $9,772.37
| Professional | | $4,786.30 | $6,606.93 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $7,585.78 / $7,585.78
| Professional | | $6,456.54 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $630.96 / $5,011.87
| Facility | | $588.84 | $630.96 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,467.37 / $6,309.57
| Professional | | $2,398.83 | $3,467.37 | $6,309.57 |