- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,467.37 / $15,488.17
| Professional | | $2,818.38 | $3,467.37 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Professional | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.62 / $4,677.35 / $5,248.07
| Facility | | $5.62 | $4,677.35 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,073.80 / $5,754.40
| Professional | | $3,467.37 | $4,073.80 | $5,754.40 |