- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,587.37 / $11,827.30 / $11,827.30
| Professional | | $2,587.37 | $11,827.30 | $11,827.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,588.06 / $3,588.06 / $3,588.06
| Facility | | $3,588.06 | $3,588.06 | $3,588.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,553.28 / $3,588.06 / $3,588.06
| Professional | | $2,553.28 | $3,588.06 | $3,588.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,588.06 / $4,028.70 / $4,177.66
| Facility | | $3,588.06 | $4,028.70 | $4,177.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.39 / $3,120.11 / $4,765.60
| Professional | | $2,202.39 | $3,120.11 | $4,765.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,168.26 / $3,977.19 / $6,293.70
| Professional | | $3,168.26 | $3,977.19 | $6,293.70 |