- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.48 / $2,425.71 / $11,096.20
| Professional | | $2,016.48 | $2,425.71 | $11,096.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,376.69 / $3,376.69 / $3,376.69
| Facility | | $3,376.69 | $3,376.69 | $3,376.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,313.92 / $3,376.69 / $3,376.69
| Professional | | $2,313.92 | $3,376.69 | $3,376.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,376.69 / $3,901.30 / $4,066.34
| Facility | | $3,376.69 | $3,901.30 | $4,066.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,067.81 / $2,929.45 / $4,474.39
| Professional | | $2,067.81 | $2,929.45 | $4,474.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,061.02 / $3,721.13 / $5,917.20
| Professional | | $3,061.02 | $3,721.13 | $5,917.20 |