- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,114.13 / $10,735.20 / $10,735.20
| Professional | | $2,114.13 | $10,735.20 | $10,735.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.58 / $3,323.58 / $3,323.58
| Facility | | $3,323.58 | $3,323.58 | $3,323.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.07 / $3,323.58 / $3,323.58
| Professional | | $1,908.07 | $3,323.58 | $3,323.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,629.15 / $3,170.09 / $3,323.58
| Facility | | $1,629.15 | $3,170.09 | $3,323.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.11 / $2,942.63 / $4,358.20
| Professional | | $2,014.11 | $2,942.63 | $4,358.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,637.26 / $3,516.53 / $5,815.47
| Professional | | $2,637.26 | $3,516.53 | $5,815.47 |