- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,007.68 / $6,245.94 / $6,432.39
| Professional | | $4,007.68 | $6,245.94 | $6,432.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,032.36 / $5,598.13 / $6,525.61
| Professional | | $4,032.36 | $5,598.13 | $6,525.61 |
- 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
- $752.44 / $6,539.60 / $12,341.25
| Professional | | $752.44 | $6,539.60 | $12,341.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.63 / $1,064.63 / $1,064.63
| Professional | | $1,064.63 | $1,064.63 | $1,064.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,040.16 / $3,009.76 / $5,016.27
| Professional | | $2,040.16 | $3,009.76 | $5,016.27 |