- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,200.98 / $14,663.60 / $14,663.60
| Professional | | $3,200.98 | $14,663.60 | $14,663.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,459.31 / $4,459.31 / $4,459.31
| Facility | | $4,459.31 | $4,459.31 | $4,459.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,232.62 / $4,459.31 / $4,459.31
| Professional | | $3,232.62 | $4,459.31 | $4,459.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,459.31 / $5,343.00 / $5,526.15
| Facility | | $4,459.31 | $5,343.00 | $5,526.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,727.43 / $3,863.93 / $5,901.70
| Professional | | $2,727.43 | $3,863.93 | $5,901.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,922.61 / $5,007.60 / $7,814.39
| Professional | | $3,922.61 | $5,007.60 | $7,814.39 |