- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.17 / $2,851.43 / $10,731.20
| Professional | | $2,187.17 | $2,851.43 | $10,731.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,234.72 / $3,234.72 / $3,234.72
| Facility | | $3,234.72 | $3,234.72 | $3,234.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.53 / $3,234.72 / $3,494.91
| Professional | | $1,108.53 | $3,234.72 | $3,494.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,134.90 / $1,600.37 / $3,234.72
| Facility | | $1,134.90 | $1,600.37 | $3,234.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.24 / $3,234.72 / $4,249.70
| Professional | | $1,863.24 | $3,234.72 | $4,249.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.98 / $3,342.08 / $3,933.60
| Professional | | $2,119.98 | $3,342.08 | $3,933.60 |