- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $9,549.93
| Professional | | $1,819.70 | $2,041.74 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.29 / $1,230.27 / $3,019.95
| Facility | | $1.29 | $1,230.27 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $3,388.44
| Professional | | $2,041.74 | $2,454.71 | $3,388.44 |