- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,084.82 / $10,699.50 / $10,699.50
| Professional | | $3,084.82 | $10,699.50 | $10,699.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,784.15 / $3,304.21 / $3,304.21
| Facility | | $1,784.15 | $3,304.21 | $3,304.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,784.15 / $2,687.03 / $3,304.21
| Professional | | $1,784.15 | $2,687.03 | $3,304.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.89 / $3,146.87 / $3,304.21
| Facility | | $1,591.89 | $3,146.87 | $3,304.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,784.15 / $2,479.96 / $3,426.40
| Professional | | $1,784.15 | $2,479.96 | $3,426.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.46 / $1,424.47 / $2,195.07
| Professional | | $1,287.46 | $1,424.47 | $2,195.07 |