- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.20 / $2,930.60 / $2,930.60
| Professional | | $1,901.20 | $2,930.60 | $2,930.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,870.05 / $5,014.00 / $9,294.37
| Facility | | $3,870.05 | $5,014.00 | $9,294.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,542.58 / $2,635.60 / $3,266.77
| Professional | | $2,542.58 | $2,635.60 | $3,266.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $3,148.57
| Facility | | $3,148.57 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $2,298.46 / $3,148.57
| Professional | | $2,298.46 | $2,298.46 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,523.06 / $3,523.06 / $3,523.06
| Professional | | $3,523.06 | $3,523.06 | $3,523.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,450.08 / $2,930.60 / $2,930.60
| Professional | | $2,450.08 | $2,930.60 | $2,930.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,587.56 / $3,175.12 / $4,992.21
| Professional | | $1,587.56 | $3,175.12 | $4,992.21 |