- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,243.36 / $5,912.29 / $10,594.08
| Professional | | $3,243.36 | $5,912.29 | $10,594.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $5,109.46
| Facility | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,343.04 / $4,343.04 / $18,539.06
| Professional | | $4,343.04 | $4,343.04 | $18,539.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,510.08 / $8,510.08 / $8,510.08
| Professional | | $8,510.08 | $8,510.08 | $8,510.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,411.60 / $4,255.04 / $6,224.41
| Professional | | $3,411.60 | $4,255.04 | $6,224.41 |