- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.50 / $1,522.50 / $1,903.13
| Professional | | $1,522.50 | $1,522.50 | $1,903.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,370.49 / $3,620.82 / $7,359.75
| Facility | | $3,370.49 | $3,620.82 | $7,359.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,620.82 / $16,162.39 / $16,162.39
| Professional | | $3,620.82 | $16,162.39 | $16,162.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,927.58 / $3,620.82 / $3,620.82
| Facility | | $2,927.58 | $3,620.82 | $3,620.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,417.35 / $3,429.32 / $3,693.83
| Professional | | $2,417.35 | $3,429.32 | $3,693.83 |