- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.60 / $2,901.55 / $5,262.46
| Professional | | $2,217.60 | $2,901.55 | $5,262.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,124.25 / $4,124.25 / $4,124.25
| Facility | | $4,124.25 | $4,124.25 | $4,124.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,505.61 / $4,124.25 / $6,506.25
| Professional | | $3,505.61 | $4,124.25 | $6,506.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,198.32 / $4,198.32 / $4,198.32
| Professional | | $4,198.32 | $4,198.32 | $4,198.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,914.59 / $2,621.14 / $3,478.83
| Professional | | $1,914.59 | $2,621.14 | $3,478.83 |