- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.48 / $2,889.06 / $2,889.06
| Professional | | $2,125.48 | $2,889.06 | $2,889.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $2,672.64
| Facility | | $2,672.64 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.73 / $2,672.64 / $4,729.50
| Professional | | $2,271.73 | $2,672.64 | $4,729.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,496.69 / $2,889.06 / $3,855.18
| Facility | | $2,496.69 | $2,889.06 | $3,855.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.18 / $3,855.18 / $3,855.18
| Professional | | $3,855.18 | $3,855.18 | $3,855.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.85 / $2,047.28 / $3,460.60
| Professional | | $1,364.85 | $2,047.28 | $3,460.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,011.90 / $19,377.48 / $19,377.48
| Facility | | $3,011.90 | $19,377.48 | $19,377.48 |