- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.32 / $2,424.07 / $11,077.70
| Professional | | $1,996.32 | $2,424.07 | $11,077.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,360.39 / $3,360.39 / $3,360.39
| Facility | | $3,360.39 | $3,360.39 | $3,360.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,419.21 / $3,360.39 / $3,360.39
| Professional | | $2,419.21 | $3,360.39 | $3,360.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,360.39 / $3,752.45 / $3,896.83
| Facility | | $3,360.39 | $3,752.45 | $3,896.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.96 / $2,922.58 / $4,463.89
| Professional | | $2,062.96 | $2,922.58 | $4,463.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,968.51 / $3,752.44 / $5,895.94
| Professional | | $2,968.51 | $3,752.44 | $5,895.94 |