- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,458.36 / $3,090.36 / $12,035.40
| Professional | | $2,458.36 | $3,090.36 | $12,035.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,847.80 / $3,847.80 / $3,847.80
| Facility | | $3,847.80 | $3,847.80 | $3,847.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,994.48 / $3,714.32 / $3,847.80
| Professional | | $1,994.48 | $3,714.32 | $3,847.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,893.78 / $2,370.14 / $3,847.80
| Facility | | $1,893.78 | $2,370.14 | $3,847.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,313.03 / $3,714.32 / $5,005.00
| Professional | | $2,313.03 | $3,714.32 | $5,005.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,270.24 / $3,896.46 / $4,453.10
| Professional | | $3,270.24 | $3,896.46 | $4,453.10 |