- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.05 / $2,582.96 / $4,784.39
| Professional | | $1,796.05 | $2,582.96 | $4,784.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $3,282.89
| Facility | | $3,282.89 | $3,282.89 | $3,282.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,790.46 / $3,282.89 / $6,731.25
| Professional | | $2,790.46 | $3,282.89 | $6,731.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,038.80 / $5,038.80 / $5,038.80
| Professional | | $5,038.80 | $5,038.80 | $5,038.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.58 / $3,813.28 / $3,813.28
| Professional | | $396.58 | $3,813.28 | $3,813.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,333.76 / $3,299.58 / $5,834.40
| Professional | | $2,333.76 | $3,299.58 | $5,834.40 |