- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,754.23 / $3,548.13
| Professional | | $1,995.26 | $2,754.23 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Professional | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,235.94 / $3,235.94
| Professional | | $2,818.38 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,818.38 / $7,413.10
| Professional | | $1,412.54 | $2,818.38 | $7,413.10 |