- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.13 / $9,780.21 / $9,780.21
| Professional | | $1,939.13 | $9,780.21 | $9,780.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,952.89 / $2,952.89 / $2,952.89
| Facility | | $2,952.89 | $2,952.89 | $2,952.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,083.04 / $2,952.89 / $3,155.60
| Professional | | $2,083.04 | $2,952.89 | $3,155.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,446.34 / $3,270.80 / $3,529.98
| Facility | | $1,446.34 | $3,270.80 | $3,529.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.60 / $2,701.18 / $3,896.20
| Professional | | $1,800.60 | $2,701.18 | $3,896.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,566.31 / $3,202.80 / $5,197.56
| Professional | | $2,566.31 | $3,202.80 | $5,197.56 |