- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,601.42 / $3,437.49 / $12,891.30
| Professional | | $2,601.42 | $3,437.49 | $12,891.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,838.34 / $3,838.34 / $3,838.34
| Facility | | $3,838.34 | $3,838.34 | $3,838.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,130.17 / $3,838.34 / $4,231.72
| Professional | | $2,130.17 | $3,838.34 | $4,231.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,893.46 / $2,603.51 / $3,838.34
| Facility | | $1,893.46 | $2,603.51 | $3,838.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,354.11 / $3,838.34 / $5,093.89
| Professional | | $2,354.11 | $3,838.34 | $5,093.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,451.17 / $4,117.42 / $4,543.35
| Professional | | $3,451.17 | $4,117.42 | $4,543.35 |