- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.58 / $2,284.59 / $10,449.40
| Professional | | $1,961.58 | $2,284.59 | $10,449.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,173.20 / $3,173.20 / $3,173.20
| Facility | | $3,173.20 | $3,173.20 | $3,173.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.57 / $3,173.20 / $3,173.20
| Professional | | $2,396.57 | $3,173.20 | $3,173.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,173.20 / $3,796.65 / $4,157.42
| Facility | | $3,173.20 | $3,796.65 | $4,157.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.53 / $2,756.22 / $4,209.80
| Professional | | $1,945.53 | $2,756.22 | $4,209.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,978.92 / $3,570.60 / $5,562.02
| Professional | | $2,978.92 | $3,570.60 | $5,562.02 |