- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,961.17 / $3,915.37 / $14,719.80
| Professional | | $2,961.17 | $3,915.37 | $14,719.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,416.18 / $4,416.18 / $4,416.18
| Facility | | $4,416.18 | $4,416.18 | $4,416.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,167.21 / $4,380.71 / $4,416.18
| Professional | | $2,167.21 | $4,380.71 | $4,416.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,171.62 / $2,985.97 / $4,416.18
| Facility | | $2,171.62 | $2,985.97 | $4,416.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,684.40 / $4,380.71 / $6,048.47
| Professional | | $2,684.40 | $4,380.71 | $6,048.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,721.98 / $4,693.35 / $5,235.45
| Professional | | $3,721.98 | $4,693.35 | $5,235.45 |