- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,090.30 / $3,715.35
| Professional | | $2,344.23 | $3,090.30 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,715.35
| Professional | | $2,691.53 | $2,691.53 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,128.61 / $6,918.31
| Professional | | $4,265.80 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $4,073.80
| Facility | | $3,388.44 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,073.80 / $11,481.54
| Professional | | $1,905.46 | $4,073.80 | $11,481.54 |