- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,914.00 / $2,564.04 / $11,840.10
| Professional | | $1,914.00 | $2,564.04 | $11,840.10 |
- 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
- $2,672.64 / $2,672.64 / $3,206.26
| Professional | | $2,672.64 | $2,672.64 | $3,206.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.36 / $611.92 / $4,812.68
| Professional | | $326.36 | $611.92 | $4,812.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,496.69 / $2,496.69 / $3,177.96
| Facility | | $2,496.69 | $2,496.69 | $3,177.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $3,206.26
| Professional | | $2,672.64 | $2,672.64 | $3,206.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,589.10 / $2,047.28 / $2,824.38
| Professional | | $1,589.10 | $2,047.28 | $2,824.38 |