- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,009.51 / $10,438.29 / $10,438.29
| Professional | | $3,009.51 | $10,438.29 | $10,438.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,711.28 / $3,480.88 / $3,480.88
| Facility | | $1,711.28 | $3,480.88 | $3,480.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,711.28 / $2,830.68 / $3,480.88
| Professional | | $1,711.28 | $2,830.68 | $3,480.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.86 / $3,315.12 / $3,480.88
| Facility | | $1,526.86 | $3,315.12 | $3,480.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,711.28 / $2,612.55 / $3,483.40
| Professional | | $1,711.28 | $2,612.55 | $3,483.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.86 / $1,366.29 / $2,277.15
| Professional | | $1,234.86 | $1,366.29 | $2,277.15 |