- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,624.64 / $16,040.40 / $16,040.40
| Professional | | $4,624.64 | $16,040.40 | $16,040.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,006.81 / $4,802.74 / $4,802.74
| Facility | | $3,006.81 | $4,802.74 | $4,802.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,006.81 / $3,905.64 / $4,802.74
| Professional | | $3,006.81 | $3,905.64 | $4,802.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,324.64 / $4,574.04 / $4,802.74
| Facility | | $2,324.64 | $4,574.04 | $4,802.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,006.81 / $3,604.68 / $4,806.24
| Professional | | $3,006.81 | $3,604.68 | $4,806.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,880.08 / $2,080.16 / $3,299.12
| Professional | | $1,880.08 | $2,080.16 | $3,299.12 |