- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.93 / $4,843.70 / $4,843.70
| Professional | | $3,311.93 | $4,843.70 | $4,843.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,396.42 / $8,287.16 / $15,361.77
| Facility | | $6,396.42 | $8,287.16 | $15,361.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,670.43 / $3,899.83 / $5,399.31
| Professional | | $3,670.43 | $3,899.83 | $5,399.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,728.96 / $4,728.96 / $5,285.93
| Facility | | $4,728.96 | $4,728.96 | $5,285.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $3,452.14 / $4,728.96
| Professional | | $3,452.14 | $3,452.14 | $4,728.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,822.91 / $5,822.91 / $5,822.91
| Professional | | $5,822.91 | $5,822.91 | $5,822.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,049.48 / $4,843.70 / $4,843.70
| Professional | | $4,049.48 | $4,843.70 | $4,843.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,391.94 / $3,587.93 / $8,251.12
| Professional | | $2,391.94 | $3,587.93 | $8,251.12 |