- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,907.22 / $2,219.35 / $10,872.90
| Professional | | $1,907.22 | $2,219.35 | $10,872.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,479.22 / $3,479.22 / $3,479.22
| Facility | | $3,479.22 | $3,479.22 | $3,479.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.54 / $3,479.22 / $3,761.47
| Professional | | $2,271.54 | $3,479.22 | $3,761.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,712.71 / $3,673.15 / $3,942.37
| Facility | | $1,712.71 | $3,673.15 | $3,942.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.48 / $3,134.55 / $4,521.30
| Professional | | $2,089.48 | $3,134.55 | $4,521.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,265.09 / $3,673.15 / $6,068.92
| Professional | | $3,265.09 | $3,673.15 | $6,068.92 |