- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.55 / $11,120.10 / $11,120.10
| Professional | | $2,326.55 | $11,120.10 | $11,120.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,301.50 / $3,301.50 / $3,301.50
| Facility | | $3,301.50 | $3,301.50 | $3,301.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,186.71 / $3,301.50 / $3,543.80
| Professional | | $2,186.71 | $3,301.50 | $3,543.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.96 / $3,601.65 / $3,922.13
| Facility | | $1,621.96 | $3,601.65 | $3,922.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.58 / $3,031.18 / $4,372.20
| Professional | | $2,020.58 | $3,031.18 | $4,372.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,838.32 / $3,563.01 / $5,820.08
| Professional | | $2,838.32 | $3,563.01 | $5,820.08 |