- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,649.57 / $4,829.95 / $8,654.67
| Professional | | $2,649.57 | $4,829.95 | $8,654.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,818.66 / $3,818.66 / $3,818.66
| Facility | | $3,818.66 | $3,818.66 | $3,818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,245.86 / $3,818.66 / $12,116.25
| Professional | | $3,245.86 | $3,818.66 | $12,116.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,952.16 / $6,952.16 / $6,952.16
| Professional | | $6,952.16 | $6,952.16 | $6,952.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,787.07 / $3,476.08 / $4,630.93
| Professional | | $2,787.07 | $3,476.08 | $4,630.93 |