- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,432.61 / $11,057.50 / $11,057.50
| Professional | | $2,432.61 | $11,057.50 | $11,057.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,381.42 / $3,381.42 / $3,381.42
| Facility | | $3,381.42 | $3,381.42 | $3,381.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.21 / $3,381.42 / $3,381.42
| Professional | | $1,665.21 | $3,381.42 | $3,381.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,702.05 / $2,844.99 / $3,381.42
| Facility | | $2,702.05 | $2,844.99 | $3,381.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.47 / $2,938.62 / $4,488.39
| Professional | | $1,906.47 | $2,938.62 | $4,488.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,660.48 / $3,703.42 / $5,923.70
| Professional | | $2,660.48 | $3,703.42 | $5,923.70 |