- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,248.07 / $6,456.54
| Professional | | $3,981.07 | $5,248.07 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Facility | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,265.80 / $4,265.80
| Professional | | $3,630.78 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $389.05 / $3,311.31
| Facility | | $371.54 | $389.05 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,818.38 / $4,677.35
| Professional | | $1,479.11 | $2,818.38 | $4,677.35 |