- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,921.21 / $4,065.36 / $5,420.48
| Professional | | $2,921.21 | $4,065.36 | $5,420.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $4,775.22
| Facility | | $4,775.22 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,058.94 / $4,775.22 / $4,775.22
| Professional | | $4,058.94 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,067.09 / $6,934.23 / $7,702.02
| Professional | | $4,067.09 | $6,934.23 | $7,702.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,821.69 / $4,104.28 / $5,130.35
| Professional | | $2,821.69 | $4,104.28 | $5,130.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,036.72 / $3,840.72 / $5,487.35
| Professional | | $3,036.72 | $3,840.72 | $5,487.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,723.24 / $5,723.24 / $5,723.24
| Professional | | $5,723.24 | $5,723.24 | $5,723.24 |