- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,658.57 / $8,241.09 / $8,725.86
| Professional | | $4,658.57 | $8,241.09 | $8,725.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.66 / $150.66 / $150.66
| Facility | | $150.66 | $150.66 | $150.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,842.44 / $5,842.44 / $5,842.44
| Professional | | $5,842.44 | $5,842.44 | $5,842.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,704.40
| Facility | | $3,704.40 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $3,704.40 / $12,836.25
| Professional | | $782.55 | $3,704.40 | $12,836.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,086.80 / $3,536.55 / $5,210.33
| Professional | | $2,086.80 | $3,536.55 | $5,210.33 |