- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,157.26 / $3,157.26 / $5,529.21
| Professional | | $3,157.26 | $3,157.26 | $5,529.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,166.52 / $6,166.52 / $6,166.52
| Facility | | $6,166.52 | $6,166.52 | $6,166.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,166.52 / $6,166.52 / $6,166.52
| Professional | | $6,166.52 | $6,166.52 | $6,166.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,943.38 / $3,943.38 / $5,894.99
| Facility | | $3,943.38 | $3,943.38 | $5,894.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,878.67 / $2,878.67 / $3,943.38
| Professional | | $2,878.67 | $2,878.67 | $3,943.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,368.73 / $3,494.42 / $4,038.60
| Professional | | $2,368.73 | $3,494.42 | $4,038.60 |