- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,193.03 / $10,038.10 / $10,038.10
| Professional | | $2,193.03 | $10,038.10 | $10,038.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,049.64 / $3,049.64 / $3,049.64
| Facility | | $3,049.64 | $3,049.64 | $3,049.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.27 / $3,049.64 / $3,049.64
| Professional | | $2,454.27 | $3,049.64 | $3,049.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,049.64 / $3,659.50 / $3,789.94
| Facility | | $3,049.64 | $3,659.50 | $3,789.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.54 / $2,647.14 / $4,043.20
| Professional | | $1,868.54 | $2,647.14 | $4,043.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,871.29 / $3,540.21 / $7,951.70
| Professional | | $2,871.29 | $3,540.21 | $7,951.70 |