- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,283.05 / $10,440.79 / $10,440.79
| Professional | | $2,283.05 | $10,440.79 | $10,440.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,172.15 / $3,172.15 / $3,172.15
| Facility | | $3,172.15 | $3,172.15 | $3,172.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.54 / $3,172.15 / $3,172.15
| Professional | | $2,006.54 | $3,172.15 | $3,172.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,172.15 / $3,328.00 / $3,400.32
| Facility | | $3,172.15 | $3,328.00 | $3,400.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,944.88 / $2,755.30 / $4,208.39
| Professional | | $1,944.88 | $2,755.30 | $4,208.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,791.79 / $3,504.60 / $5,562.95
| Professional | | $2,791.79 | $3,504.60 | $5,562.95 |