- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.38 / $1,768.71 / $9,954.42
| Professional | | $1,596.38 | $1,768.71 | $9,954.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,021.25 / $3,021.25 / $3,021.25
| Facility | | $3,021.25 | $3,021.25 | $3,021.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.96 / $3,021.25 / $3,021.25
| Professional | | $2,029.96 | $3,021.25 | $3,021.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,008.85 / $3,021.25 / $3,125.82
| Facility | | $3,008.85 | $3,021.25 | $3,125.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.98 / $2,626.52 / $4,011.70
| Professional | | $1,853.98 | $2,626.52 | $4,011.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,664.42 / $3,344.71 / $5,297.47
| Professional | | $2,664.42 | $3,344.71 | $5,297.47 |