- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,999.73 / $6,165.37 / $6,165.37
| Professional | | $3,999.73 | $6,165.37 | $6,165.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,141.76 / $10,548.41 / $19,553.41
| Facility | | $8,141.76 | $10,548.41 | $19,553.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,893.57 / $5,111.57 / $6,872.59
| Professional | | $4,893.57 | $5,111.57 | $6,872.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,417.62 / $6,541.83 / $6,728.28
| Facility | | $6,417.62 | $6,541.83 | $6,728.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $4,775.54 / $6,541.83
| Professional | | $4,775.54 | $4,775.54 | $6,541.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,411.76 / $7,411.76 / $7,411.76
| Professional | | $7,411.76 | $7,411.76 | $7,411.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,154.43 / $6,165.37 / $6,165.37
| Professional | | $5,154.43 | $6,165.37 | $6,165.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,078.97 / $6,157.94 / $12,675.51
| Professional | | $3,078.97 | $6,157.94 | $12,675.51 |