- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,141.56 / $3,141.56 / $3,141.56
| Professional | | $3,141.56 | $3,141.56 | $3,141.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,010.60 / $4,801.50 / $6,659.29
| Facility | | $2,010.60 | $4,801.50 | $6,659.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.96 / $1,507.95 / $13,612.50
| Professional | | $1,130.96 | $1,507.95 | $13,612.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,633.61 / $1,633.61 / $1,633.61
| Facility | | $1,633.61 | $1,633.61 | $1,633.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.96 / $1,507.95 / $5,127.03
| Professional | | $1,130.96 | $1,507.95 | $5,127.03 |