- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,723.84 / $3,948.48 / $4,935.60
| Professional | | $3,723.84 | $3,948.48 | $4,935.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,450.00 / $3,151.21 / $4,151.57
| Facility | | $2,450.00 | $3,151.21 | $4,151.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,793.54 / $8,793.54 / $8,793.54
| Professional | | $8,793.54 | $8,793.54 | $8,793.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,487.00 / $3,487.00 / $3,487.00
| Facility | | $3,487.00 | $3,487.00 | $3,487.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.00 / $2,831.00 / $3,775.36
| Professional | | $2,527.00 | $2,831.00 | $3,775.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.49 / $2,704.69 / $2,704.69
| Professional | | $1,929.49 | $2,704.69 | $2,704.69 |