- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,098.36 / $3,098.36 / $3,922.16
| Professional | | $3,098.36 | $3,098.36 | $3,922.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,644.69 / $3,626.76 / $3,626.76
| Facility | | $2,644.69 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.27 / $3,626.76 / $3,626.76
| Professional | | $432.27 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,965.73 / $3,098.36 / $3,922.16
| Facility | | $2,965.73 | $3,098.36 | $3,922.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,534.50 / $4,534.50 / $4,534.50
| Professional | | $4,534.50 | $4,534.50 | $4,534.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.84 / $1,510.80 / $2,518.03
| Professional | | $188.84 | $1,510.80 | $2,518.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.46 / $1,853.92 / $3,126.64
| Professional | | $1,493.46 | $1,853.92 | $3,126.64 |