- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,619.83 / $2,748.12 / $3,435.15
| Professional | | $1,619.83 | $2,748.12 | $3,435.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $5,117.10
| Facility | | $3,248.38 | $3,248.38 | $5,117.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.13 / $3,248.38 / $6,123.75
| Professional | | $415.13 | $3,248.38 | $6,123.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,679.67 / $3,685.01 / $27,719.97
| Facility | | $1,679.67 | $3,685.01 | $27,719.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.66 / $2,766.52 / $4,082.06
| Professional | | $1,763.66 | $2,766.52 | $4,082.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.66 / $2,578.14 / $3,989.88
| Professional | | $1,763.66 | $2,578.14 | $3,989.88 |