- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,814.74 / $9,762.78 / $9,762.78
| Professional | | $2,814.74 | $9,762.78 | $9,762.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,375.33 / $3,552.87 / $3,552.87
| Facility | | $2,375.33 | $3,552.87 | $3,552.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,375.33 / $2,889.23 / $3,552.87
| Professional | | $2,375.33 | $2,889.23 | $3,552.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,886.49 / $3,383.69 / $3,552.87
| Facility | | $1,886.49 | $3,383.69 | $3,552.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,375.33 / $2,666.59 / $3,555.46
| Professional | | $2,375.33 | $2,666.59 | $3,555.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.72 / $1,688.09 / $2,601.29
| Professional | | $1,525.72 | $1,688.09 | $2,601.29 |