- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,951.21 / $4,365.16
| Professional | | $1,778.28 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $5,888.44
| Facility | | $5,888.44 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,089.30 / $8,128.31
| Professional | | $1,513.56 | $2,089.30 | $8,128.31 |