- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,639.66 / $3,435.97 / $12,947.60
| Professional | | $2,639.66 | $3,435.97 | $12,947.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,898.28 / $3,898.28 / $3,898.28
| Facility | | $3,898.28 | $3,898.28 | $3,898.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,338.12 / $3,898.28 / $4,744.46
| Professional | | $2,338.12 | $3,898.28 | $4,744.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,927.67 / $2,650.55 / $3,898.28
| Facility | | $1,927.67 | $2,650.55 | $3,898.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,368.98 / $3,898.28 / $5,320.26
| Professional | | $2,368.98 | $3,898.28 | $5,320.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,638.85 / $4,252.72 / $4,618.14
| Professional | | $3,638.85 | $4,252.72 | $4,618.14 |