- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,959.02 / $2,959.02 / $3,698.78
| Professional | | $2,959.02 | $2,959.02 | $3,698.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,272.80 / $5,272.80 / $5,272.80
| Facility | | $5,272.80 | $5,272.80 | $5,272.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,923.04 / $9,923.04 / $9,923.04
| Professional | | $9,923.04 | $9,923.04 | $9,923.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,605.69 / $2,473.07 / $3,154.12
| Facility | | $1,605.69 | $2,473.07 | $3,154.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.96 / $2,647.35 / $3,544.48
| Professional | | $2,080.96 | $2,647.35 | $3,544.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $3.00 / $3,304.00
| Professional | | $3.00 | $3.00 | $3,304.00 |