- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,635.34 / $12,044.80 / $12,044.80
| Professional | | $2,635.34 | $12,044.80 | $12,044.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,656.94 / $3,656.94 / $3,656.94
| Facility | | $3,656.94 | $3,656.94 | $3,656.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,730.73 / $3,656.94 / $3,656.94
| Professional | | $2,730.73 | $3,656.94 | $3,656.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,656.94 / $4,285.18 / $4,314.70
| Facility | | $3,656.94 | $4,285.18 | $4,314.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.46 / $3,178.31 / $4,854.50
| Professional | | $2,243.46 | $3,178.31 | $4,854.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,385.38 / $4,117.80 / $6,413.02
| Professional | | $3,385.38 | $4,117.80 | $6,413.02 |