- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,047.88 / $10,048.90 / $10,048.90
| Professional | | $2,047.88 | $10,048.90 | $10,048.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,212.11 / $3,212.11 / $3,212.11
| Facility | | $3,212.11 | $3,212.11 | $3,212.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.06 / $3,212.11 / $3,477.45
| Professional | | $2,065.06 | $3,212.11 | $3,477.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,581.12 / $3,415.75 / $3,662.81
| Facility | | $1,581.12 | $3,415.75 | $3,662.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.03 / $2,893.84 / $4,174.10
| Professional | | $1,929.03 | $2,893.84 | $4,174.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,723.64 / $3,415.74 / $5,601.79
| Professional | | $2,723.64 | $3,415.74 | $5,601.79 |