- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,959.68 / $17,202.40 / $17,202.40
| Professional | | $4,959.68 | $17,202.40 | $17,202.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.78 / $5,016.95 / $5,016.95
| Facility | | $3,813.78 | $5,016.95 | $5,016.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,813.78 / $4,079.83 / $5,016.95
| Professional | | $3,813.78 | $4,079.83 | $5,016.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,493.05 / $4,778.05 / $5,016.95
| Facility | | $2,493.05 | $4,778.05 | $5,016.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,765.45 / $3,813.78 / $5,308.43
| Professional | | $3,765.45 | $3,813.78 | $5,308.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.28 / $2,230.86 / $3,437.68
| Professional | | $2,016.28 | $2,230.86 | $3,437.68 |