- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,903.27 / $2,805.27 / $10,909.50
| Professional | | $1,903.27 | $2,805.27 | $10,909.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,492.36 / $3,492.36 / $3,492.36
| Facility | | $3,492.36 | $3,492.36 | $3,492.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,849.26 / $3,492.36 / $3,771.36
| Professional | | $1,849.26 | $3,492.36 | $3,771.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,718.98 / $2,184.38 / $3,492.36
| Facility | | $1,718.98 | $2,184.38 | $3,492.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.28 / $3,492.36 / $4,536.00
| Professional | | $2,096.28 | $3,492.36 | $4,536.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,209.94 / $3,524.63 / $3,989.13
| Professional | | $3,209.94 | $3,524.63 | $3,989.13 |