- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,024.94 / $9,919.41 / $9,919.41
| Professional | | $2,024.94 | $9,919.41 | $9,919.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,175.31 / $3,175.31 / $3,175.31
| Facility | | $3,175.31 | $3,175.31 | $3,175.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.49 / $3,175.31 / $3,427.40
| Professional | | $2,020.49 | $3,175.31 | $3,427.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,562.28 / $3,376.10 / $3,616.00
| Facility | | $1,562.28 | $3,376.10 | $3,616.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,907.03 / $2,860.84 / $4,126.50
| Professional | | $1,907.03 | $2,860.84 | $4,126.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,690.74 / $3,377.75 / $5,536.12
| Professional | | $2,690.74 | $3,377.75 | $5,536.12 |