- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,381.03 / $3,506.04 / $5,539.20
| Professional | | $2,381.03 | $3,506.04 | $5,539.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,303.28
| Facility | | $4,303.28 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,657.79 / $4,303.28 / $6,776.25
| Professional | | $3,657.79 | $4,303.28 | $6,776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,419.43 / $4,419.43 / $4,419.43
| Professional | | $4,419.43 | $4,419.43 | $4,419.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.63 / $2,578.01 / $4,431.21
| Professional | | $2,031.63 | $2,578.01 | $4,431.21 |