- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,039.77 / $14,011.70 / $14,011.70
| Professional | | $4,039.77 | $14,011.70 | $14,011.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,141.52 / $3,824.37 / $3,824.37
| Facility | | $3,141.52 | $3,824.37 | $3,824.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,141.52 / $3,235.77 / $3,824.37
| Professional | | $3,141.52 | $3,235.77 | $3,824.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,030.64 / $3,642.26 / $3,824.37
| Facility | | $2,030.64 | $3,642.26 | $3,824.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.36 / $3,141.52 / $4,188.60
| Professional | | $2,870.36 | $3,141.52 | $4,188.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.31 / $1,817.08 / $2,800.07
| Professional | | $1,642.31 | $1,817.08 | $2,800.07 |