- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,169.28 / $10,644.50 / $10,644.50
| Professional | | $2,169.28 | $10,644.50 | $10,644.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,400.87 / $3,400.87 / $3,400.87
| Facility | | $3,400.87 | $3,400.87 | $3,400.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.84 / $3,400.87 / $3,686.39
| Professional | | $2,194.84 | $3,400.87 | $3,686.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,673.58 / $3,597.75 / $3,863.94
| Facility | | $1,673.58 | $3,597.75 | $3,863.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,042.58 / $3,064.18 / $4,419.80
| Professional | | $2,042.58 | $3,064.18 | $4,419.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,887.68 / $3,597.75 / $5,932.03
| Professional | | $2,887.68 | $3,597.75 | $5,932.03 |