- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,195.90 / $10,034.70 / $10,034.70
| Professional | | $2,195.90 | $10,034.70 | $10,034.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,045.43 / $3,045.43 / $3,045.43
| Facility | | $3,045.43 | $3,045.43 | $3,045.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.48 / $3,045.43 / $3,045.43
| Professional | | $2,262.48 | $3,045.43 | $3,045.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,045.43 / $3,684.85 / $3,808.28
| Facility | | $3,045.43 | $3,684.85 | $3,808.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.18 / $2,648.06 / $4,044.60
| Professional | | $1,869.18 | $2,648.06 | $4,044.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,687.45 / $3,430.80 / $5,340.02
| Professional | | $2,687.45 | $3,430.80 | $5,340.02 |