- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,467.37 / $4,365.16
| Professional | | $1,659.59 | $3,467.37 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $26,302.68 / $26,302.68
| Facility | | $2,398.83 | $26,302.68 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,630.27 / $2,951.21
| Facility | | $1,621.81 | $2,630.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,071.52 / $1,659.59
| Professional | | $776.25 | $1,071.52 | $1,659.59 |