- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,232.21 / $10,590.70 / $10,590.70
| Professional | | $2,232.21 | $10,590.70 | $10,590.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,171.63 / $3,171.63 / $3,171.63
| Facility | | $3,171.63 | $3,171.63 | $3,171.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,178.25 / $3,171.63 / $3,455.33
| Professional | | $2,178.25 | $3,171.63 | $3,455.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,557.86 / $3,554.85 / $3,839.28
| Facility | | $1,557.86 | $3,554.85 | $3,839.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.59 / $2,899.18 / $4,181.80
| Professional | | $1,932.59 | $2,899.18 | $4,181.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,789.19 / $3,415.51 / $5,579.60
| Professional | | $2,789.19 | $3,415.51 | $5,579.60 |