- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,372.03 / $2,372.03 / $3,002.96
| Professional | | $2,372.03 | $2,372.03 | $3,002.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,434.80 / $2,671.66 / $2,671.66
| Facility | | $2,434.80 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.45 / $2,671.66 / $2,671.66
| Professional | | $318.45 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,193.75 / $2,391.12 / $3,002.96
| Facility | | $2,193.75 | $2,391.12 | $3,002.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,692.10 / $3,692.10 / $3,692.10
| Professional | | $3,692.10 | $3,692.10 | $3,692.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.77 / $1,107.15 / $2,050.29
| Professional | | $153.77 | $1,107.15 | $2,050.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.89 / $1,521.81 / $2,414.37
| Professional | | $955.89 | $1,521.81 | $2,414.37 |