- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.98 / $2,674.08 / $10,397.50
| Professional | | $2,122.98 | $2,674.08 | $10,397.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,328.31 / $3,328.31 / $3,328.31
| Facility | | $3,328.31 | $3,328.31 | $3,328.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.44 / $3,328.31 / $3,594.43
| Professional | | $1,773.44 | $3,328.31 | $3,594.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,638.03 / $2,178.44 / $3,328.31
| Facility | | $1,638.03 | $2,178.44 | $3,328.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,999.23 / $3,328.31 / $4,326.00
| Professional | | $1,999.23 | $3,328.31 | $4,326.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,820.46 / $3,430.00 / $3,840.64
| Professional | | $2,820.46 | $3,430.00 | $3,840.64 |