- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.79 / $2,407.96 / $11,022.70
| Professional | | $2,043.79 | $2,407.96 | $11,022.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,354.08 / $3,354.08 / $3,354.08
| Facility | | $3,354.08 | $3,354.08 | $3,354.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,532.03 / $3,354.08 / $3,354.08
| Professional | | $2,532.03 | $3,354.08 | $3,354.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,354.08 / $3,956.55 / $4,107.46
| Facility | | $3,354.08 | $3,956.55 | $4,107.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.92 / $2,908.37 / $4,442.20
| Professional | | $2,052.92 | $2,908.37 | $4,442.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,104.37 / $3,895.67 / $8,632.79
| Professional | | $3,104.37 | $3,895.67 | $8,632.79 |