- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,079.46 / $10,715.19
| Professional | | $4,677.35 | $7,079.46 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,715.35 / $3,801.89
| Professional | | $3,162.28 | $3,715.35 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $616.60 / $4,168.69
| Facility | | $549.54 | $616.60 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,311.31 / $6,165.95
| Professional | | $2,454.71 | $3,311.31 | $6,165.95 |