- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,132.71 / $3,132.71 / $5,486.21
| Professional | | $3,132.71 | $3,132.71 | $5,486.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,118.56 / $6,118.56 / $6,118.56
| Facility | | $6,118.56 | $6,118.56 | $6,118.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,118.56 / $6,118.56 / $6,118.56
| Professional | | $6,118.56 | $6,118.56 | $6,118.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.37 / $3,745.37 / $7,621.60
| Facility | | $3,745.37 | $3,745.37 | $7,621.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $5,176.87
| Professional | | $2,734.12 | $2,734.12 | $5,176.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,351.30 / $2,601.52 / $4,008.86
| Professional | | $2,351.30 | $2,601.52 | $4,008.86 |