- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,057.13 / $2,057.13 / $2,057.13
| Professional | | $2,057.13 | $2,057.13 | $2,057.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.53 / $1,395.53 / $1,395.53
| Facility | | $1,395.53 | $1,395.53 | $1,395.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.74 / $1,018.74 / $1,018.74
| Professional | | $1,018.74 | $1,018.74 | $1,018.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $574.47 / $574.47 / $574.47
| Facility | | $574.47 | $574.47 | $574.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,694.49 / $2,281.34 / $3,602.12
| Professional | | $1,694.49 | $2,281.34 | $3,602.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $574.47 / $574.47 / $1,395.53
| Facility | | $574.47 | $574.47 | $1,395.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.74 / $1,322.87 / $2,252.09
| Professional | | $1,018.74 | $1,322.87 | $2,252.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.66 / $2,296.23 / $2,995.10
| Professional | | $1,160.66 | $2,296.23 | $2,995.10 |