- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,418.54 / $15,641.10 / $15,641.10
| Professional | | $3,418.54 | $15,641.10 | $15,641.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,715.37 / $4,715.37 / $4,715.37
| Facility | | $4,715.37 | $4,715.37 | $4,715.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,316.88 / $4,715.37 / $4,715.37
| Professional | | $3,316.88 | $4,715.37 | $4,715.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,715.37 / $5,680.35 / $5,899.33
| Facility | | $4,715.37 | $5,680.35 | $5,899.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,911.82 / $4,125.16 / $6,300.70
| Professional | | $2,911.82 | $4,125.16 | $6,300.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,456.89 / $5,345.40 / $8,288.91
| Professional | | $4,456.89 | $5,345.40 | $8,288.91 |