- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.52 / $3,448.10 / $12,969.30
| Professional | | $2,572.52 | $3,448.10 | $12,969.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,814.15 / $3,814.15 / $3,814.15
| Facility | | $3,814.15 | $3,814.15 | $3,814.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.49 / $3,402.95 / $3,814.15
| Professional | | $1,832.49 | $3,402.95 | $3,814.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,887.29 / $2,595.02 / $3,814.15
| Facility | | $1,887.29 | $2,595.02 | $3,814.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,328.55 / $3,605.91 / $5,038.60
| Professional | | $2,328.55 | $3,605.91 | $5,038.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,224.52 / $3,982.71 / $4,551.67
| Professional | | $3,224.52 | $3,982.71 | $4,551.67 |