- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.71 / $3,881.26 / $15,161.60
| Professional | | $2,675.71 | $3,881.26 | $15,161.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,835.78 / $4,835.78 / $4,835.78
| Facility | | $4,835.78 | $4,835.78 | $4,835.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,593.69 / $4,835.78 / $5,259.53
| Professional | | $2,593.69 | $4,835.78 | $5,259.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,379.31 / $3,271.55 / $4,835.78
| Facility | | $2,379.31 | $3,271.55 | $4,835.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,908.27 / $4,835.78 / $6,293.00
| Professional | | $2,908.27 | $4,835.78 | $6,293.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,129.87 / $5,096.37 / $5,901.04
| Professional | | $4,129.87 | $5,096.37 | $5,901.04 |