- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,981.07 / $6,025.60
| Professional | | $2,691.53 | $3,981.07 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,467.37 / $3,548.13
| Professional | | $2,951.21 | $3,467.37 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $2,754.23 / $4,168.69
| Facility | | $363.08 | $2,754.23 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,311.31 / $5,495.41
| Professional | | $2,089.30 | $3,311.31 | $5,495.41 |