- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,671.87 / $12,735.70 / $12,735.70
| Professional | | $3,671.87 | $12,735.70 | $12,735.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,482.86 / $3,798.11 / $3,798.11
| Facility | | $2,482.86 | $3,798.11 | $3,798.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,482.86 / $3,088.65 / $3,798.11
| Professional | | $2,482.86 | $3,088.65 | $3,798.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,845.71 / $3,617.25 / $3,798.11
| Facility | | $1,845.71 | $3,617.25 | $3,798.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,482.86 / $2,850.65 / $3,959.24
| Professional | | $2,482.86 | $2,850.65 | $3,959.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,488.46 / $2,488.46 / $2,615.05
| Facility | | $2,488.46 | $2,488.46 | $2,615.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.75 / $1,651.61 / $2,619.44
| Professional | | $1,492.75 | $1,651.61 | $2,619.44 |