- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,928.52 / $9,462.04 / $9,462.04
| Professional | | $1,928.52 | $9,462.04 | $9,462.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,029.66 / $3,029.66 / $3,029.66
| Facility | | $3,029.66 | $3,029.66 | $3,029.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,952.70 / $3,029.66 / $3,269.09
| Professional | | $1,952.70 | $3,029.66 | $3,269.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,491.24 / $3,222.70 / $3,452.82
| Facility | | $1,491.24 | $3,222.70 | $3,452.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,817.42 / $2,726.42 / $3,932.60
| Professional | | $1,817.42 | $2,726.42 | $3,932.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,562.91 / $3,217.28 / $5,280.82
| Professional | | $2,562.91 | $3,217.28 | $5,280.82 |