- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,669.56 / $13,780.10 / $13,780.10
| Professional | | $2,669.56 | $13,780.10 | $13,780.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,844.20 / $4,844.20 / $4,844.20
| Facility | | $4,844.20 | $4,844.20 | $4,844.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,952.57 / $4,844.20 / $4,844.20
| Professional | | $2,952.57 | $4,844.20 | $4,844.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,374.73 / $4,932.20 / $5,300.98
| Facility | | $2,374.73 | $4,932.20 | $5,300.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,565.67 / $3,848.91 / $5,551.70
| Professional | | $2,565.67 | $3,848.91 | $5,551.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,869.89 / $4,638.60 / $7,391.67
| Professional | | $3,869.89 | $4,638.60 | $7,391.67 |