- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,024.47 / $9,104.58 / $9,104.58
| Professional | | $2,024.47 | $9,104.58 | $9,104.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.43 / $2,780.43 / $2,780.43
| Facility | | $2,780.43 | $2,780.43 | $2,780.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,420.19 / $2,780.43 / $2,780.43
| Professional | | $2,420.19 | $2,780.43 | $2,780.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.43 / $3,332.01 / $3,339.05
| Facility | | $2,780.43 | $3,332.01 | $3,339.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,711.32 / $2,424.41 / $3,703.00
| Professional | | $1,711.32 | $2,424.41 | $3,703.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,619.87 / $3,151.21 / $4,868.26
| Professional | | $2,619.87 | $3,151.21 | $4,868.26 |