- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.90 / $4,919.97 / $8,815.96
| Professional | | $2,698.90 | $4,919.97 | $8,815.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,539.60 / $6,539.60 / $6,539.60
| Facility | | $6,539.60 | $6,539.60 | $6,539.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,558.66 / $6,539.60 / $12,341.25
| Professional | | $5,558.66 | $6,539.60 | $12,341.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,081.76 / $7,081.76 / $7,081.76
| Professional | | $7,081.76 | $7,081.76 | $7,081.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,839.01 / $3,511.39 / $5,262.48
| Professional | | $2,839.01 | $3,511.39 | $5,262.48 |