- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,167.67 / $10,986.90 / $10,986.90
| Professional | | $3,167.67 | $10,986.90 | $10,986.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $3,609.74 / $3,609.74
| Facility | | $2,050.41 | $3,609.74 | $3,609.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,050.41 / $3,609.74 / $3,609.74
| Professional | | $2,050.41 | $3,609.74 | $3,609.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,592.26 / $3,437.85 / $3,609.74
| Facility | | $1,592.26 | $3,437.85 | $3,609.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,583.56 / $2,718.75 / $3,612.36
| Professional | | $2,583.56 | $2,718.75 | $3,612.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.77 / $1,424.81 / $2,259.73
| Professional | | $1,287.77 | $1,424.81 | $2,259.73 |