- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,188.33 / $11,058.60 / $11,058.60
| Professional | | $3,188.33 | $11,058.60 | $11,058.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,540.30 / $4,168.51 / $4,168.51
| Facility | | $2,540.30 | $4,168.51 | $4,168.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,540.30 / $3,389.87 / $4,168.51
| Professional | | $2,540.30 | $3,389.87 | $4,168.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,955.82 / $3,970.01 / $4,168.51
| Facility | | $1,955.82 | $3,970.01 | $4,168.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,540.30 / $3,128.64 / $4,171.52
| Professional | | $2,540.30 | $3,128.64 | $4,171.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.79 / $1,750.12 / $2,696.88
| Professional | | $1,581.79 | $1,750.12 | $2,696.88 |