- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $5,495.41
| Professional | | $4,365.16 | $4,365.16 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $6,606.93
| Facility | | $3,090.30 | $3,090.30 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,388.44 / $10,715.19
| Professional | | $2,454.71 | $3,388.44 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,388.44
| Professional | | $3,090.30 | $3,090.30 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,388.44 / $3,388.44
| Professional | | $3,090.30 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,513.56 / $2,041.74
| Professional | | $1,230.27 | $1,513.56 | $2,041.74 |