- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,584.27 / $2,584.27 / $3,230.34
| Professional | | $2,584.27 | $2,584.27 | $3,230.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,052.73 / $5,015.51 / $5,015.51
| Facility | | $3,052.73 | $5,015.51 | $5,015.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.00 / $14,660.15 / $14,660.15
| Professional | | $2,122.00 | $14,660.15 | $14,660.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,381.63 / $2,153.09 / $2,767.34
| Facility | | $1,381.63 | $2,153.09 | $2,767.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.59 / $2,352.13 / $2,886.12
| Professional | | $1,790.59 | $2,352.13 | $2,886.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,069.00 / $7,069.00 / $7,092.00
| Facility | | $7,069.00 | $7,069.00 | $7,092.00 |