- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,435.95 / $15,552.10 / $15,552.10
| Professional | | $3,435.95 | $15,552.10 | $15,552.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,723.26 / $4,723.26 / $4,723.26
| Facility | | $4,723.26 | $4,723.26 | $4,723.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,202.82 / $4,723.26 / $5,213.56
| Professional | | $3,202.82 | $4,723.26 | $5,213.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,321.60 / $5,053.75 / $5,245.96
| Facility | | $2,321.60 | $5,053.75 | $5,245.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,897.59 / $4,346.83 / $6,269.90
| Professional | | $2,897.59 | $4,346.83 | $6,269.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,165.13 / $5,139.96 / $8,282.44
| Professional | | $4,165.13 | $5,139.96 | $8,282.44 |