- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,308.12 / $15,078.30 / $15,078.30
| Professional | | $3,308.12 | $15,078.30 | $15,078.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,540.81 / $4,540.81 / $4,540.81
| Facility | | $4,540.81 | $4,540.81 | $4,540.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,314.82 / $4,540.81 / $4,540.81
| Professional | | $3,314.82 | $4,540.81 | $4,540.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,540.81 / $5,531.50 / $5,726.02
| Facility | | $4,540.81 | $5,531.50 | $5,726.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,819.63 / $3,994.54 / $6,101.20
| Professional | | $2,819.63 | $3,994.54 | $6,101.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,340.10 / $5,148.01 / $7,979.04
| Professional | | $4,340.10 | $5,148.01 | $7,979.04 |