- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,921.75 / $13,602.40 / $13,602.40
| Professional | | $3,921.75 | $13,602.40 | $13,602.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,768.80 / $4,768.80 / $4,768.80
| Professional | | $4,768.80 | $4,768.80 | $4,768.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.72 / $5,127.41 / $5,127.41
| Facility | | $2,886.72 | $5,127.41 | $5,127.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,886.72 / $4,169.66 / $5,127.41
| Professional | | $2,886.72 | $4,169.66 | $5,127.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,405.71 / $4,883.25 / $5,127.41
| Facility | | $2,405.71 | $4,883.25 | $5,127.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,886.72 / $3,848.35 / $5,131.13
| Professional | | $2,886.72 | $3,848.35 | $5,131.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.66 / $2,152.71 / $3,317.27
| Professional | | $1,945.66 | $2,152.71 | $3,317.27 |