- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.57 / $10,685.60 / $10,685.60
| Professional | | $1,968.57 | $10,685.60 | $10,685.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,166.89 / $3,166.89 / $3,166.89
| Facility | | $3,166.89 | $3,166.89 | $3,166.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.09 / $3,166.89 / $3,414.59
| Professional | | $2,238.09 | $3,166.89 | $3,414.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,568.00 / $3,528.20 / $3,815.24
| Facility | | $1,568.00 | $3,528.20 | $3,815.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.00 / $2,895.30 / $4,176.20
| Professional | | $1,930.00 | $2,895.30 | $4,176.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,773.46 / $3,473.91 / $5,564.78
| Professional | | $2,773.46 | $3,473.91 | $5,564.78 |