- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.54 / $3,088.92 / $10,772.90
| Professional | | $2,023.54 | $3,088.92 | $10,772.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,269.95 / $3,269.95 / $3,269.95
| Facility | | $3,269.95 | $3,269.95 | $3,269.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.77 / $3,269.95 / $3,269.95
| Professional | | $2,429.77 | $3,269.95 | $3,269.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,269.95 / $3,963.70 / $4,046.10
| Facility | | $3,269.95 | $3,963.70 | $4,046.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.38 / $2,841.00 / $4,339.30
| Professional | | $2,005.38 | $2,841.00 | $4,339.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,109.98 / $3,681.61 / $5,734.07
| Professional | | $3,109.98 | $3,681.61 | $5,734.07 |