- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,691.37 / $12,803.30 / $12,803.30
| Professional | | $3,691.37 | $12,803.30 | $12,803.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $4,826.18 / $4,826.18
| Facility | | $2,941.06 | $4,826.18 | $4,826.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,941.06 / $4,826.18 / $4,826.18
| Professional | | $2,941.06 | $4,826.18 | $4,826.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $4,596.35 / $4,826.18
| Facility | | $2,941.06 | $4,596.35 | $4,826.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,574.59 / $3,702.54 / $4,829.68
| Professional | | $3,574.59 | $3,702.54 | $4,829.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.34 / $2,026.24 / $3,122.37
| Professional | | $1,831.34 | $2,026.24 | $3,122.37 |