- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.13 / $1,943.13 / $10,945.20
| Professional | | $1,943.13 | $1,943.13 | $10,945.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,501.83 / $3,501.83 / $3,501.83
| Facility | | $3,501.83 | $3,501.83 | $3,501.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,275.42 / $3,501.83 / $3,787.07
| Professional | | $2,275.42 | $3,501.83 | $3,787.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,723.28 / $3,732.95 / $3,995.50
| Facility | | $1,723.28 | $3,732.95 | $3,995.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,103.71 / $3,155.91 / $4,552.10
| Professional | | $2,103.71 | $3,155.91 | $4,552.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,286.92 / $3,729.38 / $6,106.83
| Professional | | $3,286.92 | $3,729.38 | $6,106.83 |