- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,094.46 / $10,733.00 / $10,733.00
| Professional | | $3,094.46 | $10,733.00 | $10,733.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,381.07 / $4,053.89 / $4,053.89
| Facility | | $2,381.07 | $4,053.89 | $4,053.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,381.07 / $4,053.89 / $4,053.89
| Professional | | $2,381.07 | $4,053.89 | $4,053.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,381.07 / $3,860.85 / $4,053.89
| Facility | | $2,381.07 | $3,860.85 | $4,053.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,381.07 / $3,042.62 / $4,056.83
| Professional | | $2,381.07 | $3,042.62 | $4,056.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,570.89 / $1,699.03 / $2,694.65
| Professional | | $1,570.89 | $1,699.03 | $2,694.65 |