- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $5,754.40
| Professional | | $4,570.88 | $4,570.88 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,079.46
| Facility | | $3,235.94 | $3,235.94 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,548.13 / $11,220.18
| Professional | | $2,691.53 | $3,548.13 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,467.37
| Professional | | $3,235.94 | $3,235.94 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,630.78
| Professional | | $3,548.13 | $3,548.13 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,584.89 / $2,137.96
| Professional | | $1,348.96 | $1,584.89 | $2,137.96 |