- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,066.66 / $4,727.10 / $4,727.10
| Professional | | $3,066.66 | $4,727.10 | $4,727.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,242.43 / $8,087.65 / $14,991.94
| Facility | | $6,242.43 | $8,087.65 | $14,991.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,205.32 / $3,405.65 / $5,269.32
| Professional | | $3,205.32 | $3,405.65 | $5,269.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.36 / $4,072.36 / $5,158.66
| Facility | | $4,072.36 | $4,072.36 | $5,158.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $2,972.82 / $4,072.36
| Professional | | $2,972.82 | $2,972.82 | $4,072.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,682.72 / $5,682.72 / $5,682.72
| Professional | | $5,682.72 | $5,682.72 | $5,682.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,951.99 / $4,727.10 / $4,727.10
| Professional | | $3,951.99 | $4,727.10 | $4,727.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.37 / $4,011.56 / $8,052.49
| Professional | | $2,334.37 | $4,011.56 | $8,052.49 |