- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,338.06 / $10,701.40 / $10,701.40
| Professional | | $2,338.06 | $10,701.40 | $10,701.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,250.50 / $3,250.50 / $3,250.50
| Facility | | $3,250.50 | $3,250.50 | $3,250.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,626.32 / $3,250.50 / $3,250.50
| Professional | | $2,626.32 | $3,250.50 | $3,250.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,250.50 / $3,583.75 / $3,634.15
| Facility | | $3,250.50 | $3,583.75 | $3,634.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.79 / $2,821.75 / $4,309.89
| Professional | | $1,991.79 | $2,821.75 | $4,309.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,862.30 / $3,593.11 / $5,696.13
| Professional | | $2,862.30 | $3,593.11 | $5,696.13 |