- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,479.11 / $2,691.53
| Professional | | $1,288.25 | $1,479.11 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,025.60 / $6,025.60
| Professional | | $3,715.35 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,570.40 / $3,801.89
| Professional | | $1,659.59 | $2,570.40 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,168.69 / $14,125.38
| Facility | | $1,659.59 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,691.53 / $5,128.61
| Professional | | $1,513.56 | $2,691.53 | $5,128.61 |