- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,224.92 / $10,920.20 / $10,920.20
| Professional | | $2,224.92 | $10,920.20 | $10,920.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,492.89 / $3,492.89 / $3,492.89
| Facility | | $3,492.89 | $3,492.89 | $3,492.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,259.15 / $3,492.89 / $3,784.75
| Professional | | $2,259.15 | $3,492.89 | $3,784.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,719.70 / $3,715.40 / $3,983.49
| Facility | | $1,719.70 | $3,715.40 | $3,983.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,094.98 / $3,142.80 / $4,533.20
| Professional | | $2,094.98 | $3,142.80 | $4,533.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,962.87 / $3,658.23 / $6,085.57
| Professional | | $2,962.87 | $3,658.23 | $6,085.57 |