- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,567.75 / $3,567.75 / $6,248.10
| Professional | | $3,567.75 | $3,567.75 | $6,248.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,968.26 / $6,968.26 / $6,968.26
| Facility | | $6,968.26 | $6,968.26 | $6,968.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,968.26 / $6,968.26 / $6,968.26
| Professional | | $6,968.26 | $6,968.26 | $6,968.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,865.01 / $4,865.01 / $8,064.76
| Facility | | $4,865.01 | $4,865.01 | $8,064.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,551.46 / $3,551.46 / $4,865.01
| Professional | | $3,551.46 | $3,551.46 | $4,865.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,783.41 / $4,106.16 / $4,745.60
| Professional | | $2,783.41 | $4,106.16 | $4,745.60 |