- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,107.96 / $14,846.80 / $14,846.80
| Professional | | $3,107.96 | $14,846.80 | $14,846.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,407.78 / $4,407.78 / $4,407.78
| Facility | | $4,407.78 | $4,407.78 | $4,407.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,920.65 / $4,407.78 / $4,759.60
| Professional | | $2,920.65 | $4,407.78 | $4,759.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,163.71 / $4,865.89 / $5,260.50
| Facility | | $2,163.71 | $4,865.89 | $5,260.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.52 / $4,037.70 / $5,824.00
| Professional | | $2,691.52 | $4,037.70 | $5,824.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.87 / $4,791.04 / $7,761.65
| Professional | | $3,817.87 | $4,791.04 | $7,761.65 |