- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,239.02 / $2,503.11 / $3,214.07
| Professional | | $2,239.02 | $2,503.11 | $3,214.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.40 / $3,311.40 / $3,311.40
| Facility | | $3,311.40 | $3,311.40 | $3,311.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.40 / $3,311.40 / $3,311.40
| Professional | | $3,311.40 | $3,311.40 | $3,311.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $3,407.14
| Facility | | $2,672.64 | $2,672.64 | $3,407.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.73 / $2,672.64 / $3,206.26
| Professional | | $2,271.73 | $2,672.64 | $3,206.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.85 / $2,308.91 / $5,118.20
| Professional | | $1,364.85 | $2,308.91 | $5,118.20 |