- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,027.95 / $3,795.76 / $14,830.40
| Professional | | $3,027.95 | $3,795.76 | $14,830.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,730.10 / $4,730.10 / $4,730.10
| Facility | | $4,730.10 | $4,730.10 | $4,730.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,535.69 / $4,730.10 / $5,146.63
| Professional | | $2,535.69 | $4,730.10 | $5,146.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,327.21 / $3,121.99 / $4,730.10
| Facility | | $2,327.21 | $3,121.99 | $4,730.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,845.51 / $4,730.10 / $6,157.20
| Professional | | $2,845.51 | $4,730.10 | $6,157.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,973.41 / $4,815.42 / $7,051.16
| Professional | | $3,973.41 | $4,815.42 | $7,051.16 |