- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,830.47 / $3,830.47 / $6,708.18
| Professional | | $3,830.47 | $3,830.47 | $6,708.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,481.38 / $7,481.38 / $7,481.38
| Facility | | $7,481.38 | $7,481.38 | $7,481.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,481.38 / $7,481.38 / $7,481.38
| Professional | | $7,481.38 | $7,481.38 | $7,481.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,938.58 / $4,938.58 / $7,839.21
| Facility | | $4,938.58 | $4,938.58 | $7,839.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,605.16 / $3,605.16 / $4,938.58
| Professional | | $3,605.16 | $3,605.16 | $4,938.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,213.38 / $3,555.35 / $5,478.69
| Professional | | $3,213.38 | $3,555.35 | $5,478.69 |