- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,091.40 / $10,722.30 / $10,722.30
| Professional | | $3,091.40 | $10,722.30 | $10,722.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.07 / $4,041.78 / $4,041.78
| Facility | | $2,463.07 | $4,041.78 | $4,041.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,463.07 / $3,286.81 / $4,041.78
| Professional | | $2,463.07 | $3,286.81 | $4,041.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,896.34 / $3,849.31 / $4,041.78
| Facility | | $1,896.34 | $3,849.31 | $4,041.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,463.07 / $3,033.53 / $4,044.71
| Professional | | $2,463.07 | $3,033.53 | $4,044.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.70 / $1,696.91 / $2,691.29
| Professional | | $1,533.70 | $1,696.91 | $2,691.29 |