- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.71 / $10,346.40 / $10,346.40
| Professional | | $2,260.71 | $10,346.40 | $10,346.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.23 / $3,143.23 / $3,143.23
| Facility | | $3,143.23 | $3,143.23 | $3,143.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,315.96 / $3,143.23 / $3,143.23
| Professional | | $2,315.96 | $3,143.23 | $3,143.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.23 / $3,804.45 / $4,041.04
| Facility | | $3,143.23 | $3,804.45 | $4,041.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,926.12 / $2,728.72 / $4,167.80
| Professional | | $1,926.12 | $2,728.72 | $4,167.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.41 / $3,531.60 / $8,242.09
| Professional | | $2,766.41 | $3,531.60 | $8,242.09 |