- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.72 / $9,049.41 / $9,049.41
| Professional | | $1,996.72 | $9,049.41 | $9,049.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.77 / $2,756.77 / $2,756.77
| Facility | | $2,756.77 | $2,756.77 | $2,756.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.71 / $2,756.77 / $2,846.56
| Professional | | $2,052.71 | $2,756.77 | $2,846.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,356.47 / $3,277.95 / $3,363.64
| Facility | | $1,356.47 | $3,277.95 | $3,363.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.38 / $2,531.32 / $3,651.20
| Professional | | $1,687.38 | $2,531.32 | $3,651.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,571.92 / $3,082.20 / $4,828.49
| Professional | | $2,571.92 | $3,082.20 | $4,828.49 |