- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,504.44 / $4,594.89 / $17,073.50
| Professional | | $3,504.44 | $4,594.89 | $17,073.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,161.78 / $5,161.78 / $5,161.78
| Facility | | $5,161.78 | $5,161.78 | $5,161.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,206.61 / $4,520.39 / $5,161.78
| Professional | | $2,206.61 | $4,520.39 | $5,161.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,542.77 / $3,215.34 / $5,161.78
| Facility | | $2,542.77 | $3,215.34 | $5,161.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,082.70 / $4,859.39 / $6,827.80
| Professional | | $3,082.70 | $4,859.39 | $6,827.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,206.14 / $5,200.78 / $6,051.82
| Professional | | $4,206.14 | $5,200.78 | $6,051.82 |