- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,222.71 / $5,874.82 / $10,526.91
| Professional | | $3,222.71 | $5,874.82 | $10,526.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $4,978.93 / $4,978.93
| Facility | | $4,978.93 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,232.09 / $4,978.93 / $14,737.50
| Professional | | $4,232.09 | $4,978.93 | $14,737.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,456.16 / $8,456.16 / $8,456.16
| Professional | | $8,456.16 | $8,456.16 | $8,456.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,389.97 / $4,192.85 / $7,780.45
| Professional | | $3,389.97 | $4,192.85 | $7,780.45 |