- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $3,630.78
| Professional | | $2,570.40 | $3,311.31 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,025.60 / $12,302.69
| Professional | | $4,786.30 | $6,025.60 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $7,762.47 / $7,762.47
| Facility | | $7,762.47 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Facility | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $3,890.45
| Professional | | $1,621.81 | $1,621.81 | $3,890.45 |