- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,222.71 / $5,348.61 / $10,526.91
| Professional | | $3,222.71 | $5,348.61 | $10,526.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,300.15 / $5,300.15 / $5,406.15
| Facility | | $5,300.15 | $5,300.15 | $5,406.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,505.13 / $5,300.15 / $14,737.50
| Professional | | $4,505.13 | $5,300.15 | $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
- $2,994.90 / $4,228.08 / $5,243.29
| Professional | | $2,994.90 | $4,228.08 | $5,243.29 |