- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $3,981.07
| Professional | | $1,995.26 | $2,691.53 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $5,128.61
| Professional | | $2,290.87 | $2,691.53 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,388.44 / $3,388.44
| Professional | | $3,311.31 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $446.68 / $3,019.95
| Facility | | $234.42 | $446.68 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,089.30 / $3,311.31
| Professional | | $1,548.82 | $2,089.30 | $3,311.31 |