- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,423.03 / $11,872.60 / $11,872.60
| Professional | | $3,423.03 | $11,872.60 | $11,872.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.85 / $5,094.52 / $5,094.52
| Facility | | $2,970.85 | $5,094.52 | $5,094.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,970.85 / $4,142.91 / $5,094.52
| Professional | | $2,970.85 | $4,142.91 | $5,094.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,064.78 / $4,851.92 / $5,094.52
| Facility | | $2,064.78 | $4,851.92 | $5,094.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,970.85 / $3,823.66 / $5,098.21
| Professional | | $2,970.85 | $3,823.66 | $5,098.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,669.91 / $1,847.62 / $2,847.13
| Professional | | $1,669.91 | $1,847.62 | $2,847.13 |