- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,845.96 / $2,845.97 / $3,130.56
| Professional | | $2,845.96 | $2,845.97 | $3,130.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,184.52 / $8,023.90 / $20,446.77
| Facility | | $5,184.52 | $8,023.90 | $20,446.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $5,233.81
| Professional | | $2,914.55 | $2,914.55 | $5,233.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,184.52 / $8,023.90 / $20,446.77
| Facility | | $5,184.52 | $8,023.90 | $20,446.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.55 / $4,206.74 / $5,771.76
| Professional | | $2,914.55 | $4,206.74 | $5,771.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.40 / $2,857.40 / $2,857.40
| Professional | | $2,857.40 | $2,857.40 | $2,857.40 |