- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.83 / $9,546.20 / $9,546.20
| Professional | | $2,123.83 | $9,546.20 | $9,546.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,916.61 / $2,916.61 / $2,916.61
| Facility | | $2,916.61 | $2,916.61 | $2,916.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,363.08 / $2,916.61 / $2,916.61
| Professional | | $2,363.08 | $2,916.61 | $2,916.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,916.61 / $3,722.55 / $3,814.61
| Facility | | $2,916.61 | $3,722.55 | $3,814.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,795.10 / $2,543.11 / $3,884.30
| Professional | | $1,795.10 | $2,543.11 | $3,884.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,864.17 / $3,304.81 / $5,107.84
| Professional | | $2,864.17 | $3,304.81 | $5,107.84 |