- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,653.61 / $11,084.60 / $11,084.60
| Professional | | $2,653.61 | $11,084.60 | $11,084.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,285.72 / $3,285.72 / $3,285.72
| Facility | | $3,285.72 | $3,285.72 | $3,285.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,419.71 / $3,285.72 / $3,528.08
| Professional | | $2,419.71 | $3,285.72 | $3,528.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,624.18 / $3,956.55 / $4,041.68
| Facility | | $1,624.18 | $3,956.55 | $4,041.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.85 / $2,985.08 / $4,305.70
| Professional | | $1,989.85 | $2,985.08 | $4,305.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,104.37 / $3,596.64 / $5,722.04
| Professional | | $3,104.37 | $3,596.64 | $5,722.04 |