- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.28 / $9,505.67 / $9,505.67
| Professional | | $1,938.28 | $9,505.67 | $9,505.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,040.70 / $3,040.70 / $3,040.70
| Facility | | $3,040.70 | $3,040.70 | $3,040.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,952.08 / $3,040.70 / $3,292.96
| Professional | | $1,952.08 | $3,040.70 | $3,292.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,496.54 / $3,105.70 / $3,367.43
| Facility | | $1,496.54 | $3,105.70 | $3,367.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,824.86 / $2,737.58 / $3,948.70
| Professional | | $1,824.86 | $2,737.58 | $3,948.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,771.24 / $3,205.68 / $5,301.18
| Professional | | $2,771.24 | $3,205.68 | $5,301.18 |