- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.26 / $2,345.36 / $11,496.60
| Professional | | $1,858.26 | $2,345.36 | $11,496.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,470.81 / $3,470.81 / $3,470.81
| Facility | | $3,470.81 | $3,470.81 | $3,470.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.08 / $3,470.81 / $3,735.86
| Professional | | $1,851.08 | $3,470.81 | $3,735.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,716.85 / $2,360.67 / $3,470.81
| Facility | | $1,716.85 | $2,360.67 | $3,470.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,106.63 / $3,470.81 / $4,731.92
| Professional | | $2,106.63 | $3,470.81 | $4,731.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,003.76 / $3,706.78 / $4,090.24
| Professional | | $3,003.76 | $3,706.78 | $4,090.24 |