- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,195.06 / $10,755.60 / $10,755.60
| Professional | | $2,195.06 | $10,755.60 | $10,755.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,441.89 / $3,441.89 / $3,441.89
| Facility | | $3,441.89 | $3,441.89 | $3,441.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,218.96 / $3,441.89 / $3,720.73
| Professional | | $2,218.96 | $3,441.89 | $3,720.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,694.43 / $3,656.25 / $3,917.07
| Facility | | $1,694.43 | $3,656.25 | $3,917.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.84 / $3,100.58 / $4,472.30
| Professional | | $2,066.84 | $3,100.58 | $4,472.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,918.69 / $3,656.24 / $6,006.03
| Professional | | $2,918.69 | $3,656.24 | $6,006.03 |