- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.32 / $2,132.73 / $10,365.29
| Professional | | $1,819.32 | $2,132.73 | $10,365.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,134.82 / $3,134.82 / $3,134.82
| Facility | | $3,134.82 | $3,134.82 | $3,134.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.62 / $3,134.82 / $3,134.82
| Professional | | $2,243.62 | $3,134.82 | $3,134.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,134.82 / $3,734.90 / $3,870.90
| Facility | | $3,134.82 | $3,734.90 | $3,870.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,924.83 / $2,726.89 / $4,165.00
| Professional | | $1,924.83 | $2,726.89 | $4,165.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,930.47 / $3,647.47 / $5,493.56
| Professional | | $2,930.47 | $3,647.47 | $5,493.56 |