- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.97 / $8,879.54 / $8,879.54
| Professional | | $1,974.97 | $8,879.54 | $8,879.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,713.13 / $2,713.13 / $2,713.13
| Facility | | $2,713.13 | $2,713.13 | $2,713.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,197.37 / $2,713.13 / $2,713.13
| Professional | | $2,197.37 | $2,713.13 | $2,713.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,713.13 / $3,461.90 / $3,548.33
| Facility | | $2,713.13 | $3,461.90 | $3,548.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,669.58 / $2,365.29 / $3,612.70
| Professional | | $1,669.58 | $2,365.29 | $3,612.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,662.93 / $3,072.60 / $4,752.63
| Professional | | $2,662.93 | $3,072.60 | $4,752.63 |