- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,965.63 / $17,981.50 / $17,981.50
| Professional | | $3,965.63 | $17,981.50 | $17,981.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,469.37 / $5,469.37 / $5,469.37
| Facility | | $5,469.37 | $5,469.37 | $5,469.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,532.62 / $5,469.37 / $6,011.48
| Professional | | $3,532.62 | $5,469.37 | $6,011.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,689.34 / $6,329.70 / $6,600.77
| Facility | | $2,689.34 | $6,329.70 | $6,600.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,348.55 / $5,023.34 / $7,245.70
| Professional | | $3,348.55 | $5,023.34 | $7,245.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,966.38 / $6,136.80 / $9,580.21
| Professional | | $4,966.38 | $6,136.80 | $9,580.21 |