- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,597.50 / $4,310.88 / $8,484.50
| Professional | | $2,597.50 | $4,310.88 | $8,484.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.57 / $4,321.80 / $4,321.80
| Facility | | $775.57 | $4,321.80 | $4,321.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,673.53 / $3,673.53 / $14,850.00
| Professional | | $3,673.53 | $3,673.53 | $14,850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,815.52 / $6,815.52 / $6,815.52
| Professional | | $6,815.52 | $6,815.52 | $6,815.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.27 / $3,407.76 / $6,270.91
| Professional | | $2,732.27 | $3,407.76 | $6,270.91 |