- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,388.44 / $3,715.35
| Professional | | $3,090.30 | $3,388.44 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,630.78
| Professional | | $3,090.30 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $354.81 / $2,754.23
| Facility | | $245.47 | $354.81 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,344.23 / $3,890.45
| Professional | | $1,819.70 | $2,344.23 | $3,890.45 |