- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.83 / $10,108.70 / $10,108.70
| Professional | | $2,058.83 | $10,108.70 | $10,108.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,226.83 / $3,226.83 / $3,226.83
| Facility | | $3,226.83 | $3,226.83 | $3,226.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,018.24 / $3,226.83 / $3,226.83
| Professional | | $2,018.24 | $3,226.83 | $3,226.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,588.22 / $3,439.15 / $3,733.65
| Facility | | $1,588.22 | $3,439.15 | $3,733.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,937.44 / $2,906.46 / $4,192.30
| Professional | | $1,937.44 | $2,906.46 | $4,192.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,744.79 / $3,439.15 / $5,627.70
| Professional | | $2,744.79 | $3,439.15 | $5,627.70 |