- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,676.88 / $12,753.10 / $12,753.10
| Professional | | $3,676.88 | $12,753.10 | $12,753.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.76 / $4,252.68 / $4,252.68
| Facility | | $2,637.76 | $4,252.68 | $4,252.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,637.76 / $3,458.32 / $4,252.68
| Professional | | $2,637.76 | $3,458.32 | $4,252.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,848.23 / $4,050.18 / $4,252.68
| Facility | | $1,848.23 | $4,050.18 | $4,252.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,637.76 / $3,191.83 / $4,255.78
| Professional | | $2,637.76 | $3,191.83 | $4,255.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.78 / $1,653.86 / $2,548.54
| Professional | | $1,494.78 | $1,653.86 | $2,548.54 |