- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,965.78 / $3,868.01 / $14,515.10
| Professional | | $2,965.78 | $3,868.01 | $14,515.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,386.22 / $4,386.22 / $4,386.22
| Facility | | $4,386.22 | $4,386.22 | $4,386.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.13 / $3,620.04 / $4,386.22
| Professional | | $2,116.13 | $3,620.04 | $4,386.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,168.42 / $2,914.04 / $4,374.37
| Facility | | $2,168.42 | $2,914.04 | $4,374.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,664.99 / $4,121.62 / $5,766.60
| Professional | | $2,664.99 | $4,121.62 | $5,766.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,860.24 / $4,354.58 / $5,110.96
| Professional | | $2,860.24 | $4,354.58 | $5,110.96 |