- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,349.58 / $5,690.96 / $10,591.03
| Professional | | $4,349.58 | $5,690.96 | $10,591.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,391.94 / $8,391.94 / $8,391.94
| Facility | | $8,391.94 | $8,391.94 | $8,391.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,133.15 / $7,133.15 / $16,584.38
| Professional | | $7,133.15 | $7,133.15 | $16,584.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,448.56 / $8,448.56 / $8,448.56
| Professional | | $8,448.56 | $8,448.56 | $8,448.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,737.14 / $5,157.60 / $7,456.25
| Professional | | $3,737.14 | $5,157.60 | $7,456.25 |