- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,856.03 / $13,590.40 / $13,590.40
| Professional | | $1,856.03 | $13,590.40 | $13,590.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,507.59 / $3,709.38 / $3,709.38
| Facility | | $2,507.59 | $3,709.38 | $3,709.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,507.59 / $3,016.51 / $3,709.38
| Professional | | $2,507.59 | $3,016.51 | $3,709.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,969.58 / $3,532.74 / $3,709.38
| Facility | | $1,969.58 | $3,532.74 | $3,709.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,507.59 / $2,784.05 / $4,061.25
| Professional | | $2,507.59 | $2,784.05 | $4,061.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,592.93 / $1,762.45 / $2,080.46
| Professional | | $1,592.93 | $1,762.45 | $2,080.46 |