- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,807.04 / $5,116.93 / $9,168.84
| Professional | | $2,807.04 | $5,116.93 | $9,168.84 |
- 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
- $3,148.74 / $3,704.40 / $12,836.25
| Professional | | $3,148.74 | $3,704.40 | $12,836.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,365.20 / $7,365.20 / $7,365.20
| Professional | | $7,365.20 | $7,365.20 | $7,365.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,952.64 / $3,682.60 / $5,473.30
| Professional | | $2,952.64 | $3,682.60 | $5,473.30 |