- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.89 / $4,385.70 / $6,929.38
| Professional | | $2,870.89 | $4,385.70 | $6,929.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,649.60 / $5,470.13 / $8,643.75
| Professional | | $4,649.60 | $5,470.13 | $8,643.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.63 / $5,527.76 / $5,527.76
| Professional | | $510.63 | $5,527.76 | $5,527.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,487.48 / $3,404.22 / $4,521.75
| Professional | | $2,487.48 | $3,404.22 | $4,521.75 |