- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.85 / $15,943.70 / $15,943.70
| Professional | | $3,251.85 | $15,943.70 | $15,943.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,090.27 / $5,090.27 / $5,090.27
| Facility | | $5,090.27 | $5,090.27 | $5,090.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,328.22 / $5,090.27 / $5,515.61
| Professional | | $3,328.22 | $5,090.27 | $5,515.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,504.65 / $5,427.50 / $5,809.51
| Facility | | $2,504.65 | $5,427.50 | $5,809.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,059.02 / $4,589.00 / $6,619.20
| Professional | | $3,059.02 | $4,589.00 | $6,619.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,338.55 / $5,353.97 / $8,882.77
| Professional | | $4,338.55 | $5,353.97 | $8,882.77 |