- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,632.73 / $11,972.60 / $11,972.60
| Professional | | $2,632.73 | $11,972.60 | $11,972.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,624.87 / $3,624.87 / $3,624.87
| Facility | | $3,624.87 | $3,624.87 | $3,624.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,528.08 / $3,624.87 / $3,983.21
| Professional | | $2,528.08 | $3,624.87 | $3,983.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,781.88 / $4,289.35 / $4,455.33
| Facility | | $1,781.88 | $4,289.35 | $4,455.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,221.46 / $3,332.56 / $4,806.89
| Professional | | $2,221.46 | $3,332.56 | $4,806.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,365.49 / $4,085.40 / $6,353.81
| Professional | | $3,365.49 | $4,085.40 | $6,353.81 |