- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,388.79 / $2,628.68 / $3,285.85
| Professional | | $2,388.79 | $2,628.68 | $3,285.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,942.77 / $2,160.98 / $2,596.38
| Facility | | $1,942.77 | $2,160.98 | $2,596.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,682.00 / $15,682.00 / $15,682.00
| Professional | | $15,682.00 | $15,682.00 | $15,682.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,412.00 / $2,412.00 / $2,412.00
| Facility | | $2,412.00 | $2,412.00 | $2,412.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,208.00 / $2,513.00 / $2,555.06
| Professional | | $2,208.00 | $2,513.00 | $2,555.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.31 / $2,229.14 / $2,229.14
| Professional | | $1,407.31 | $2,229.14 | $2,229.14 |