- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.05 / $9,904.12 / $9,904.12
| Professional | | $1,954.05 | $9,904.12 | $9,904.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,974.45 / $2,974.45 / $2,974.45
| Facility | | $2,974.45 | $2,974.45 | $2,974.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.11 / $2,974.45 / $3,233.01
| Professional | | $2,138.11 | $2,974.45 | $3,233.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,458.86 / $3,363.10 / $3,617.27
| Facility | | $1,458.86 | $3,363.10 | $3,617.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.60 / $2,717.68 / $3,920.00
| Professional | | $1,811.60 | $2,717.68 | $3,920.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,638.74 / $3,252.01 / $5,231.79
| Professional | | $2,638.74 | $3,252.01 | $5,231.79 |