- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.07 / $9,593.95 / $9,593.95
| Professional | | $2,766.07 | $9,593.95 | $9,593.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.77 / $3,647.47 / $3,647.47
| Facility | | $2,571.77 | $3,647.47 | $3,647.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,571.77 / $2,966.16 / $3,647.47
| Professional | | $2,571.77 | $2,966.16 | $3,647.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,712.10 / $3,473.78 / $3,647.47
| Facility | | $1,712.10 | $3,473.78 | $3,647.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,571.77 / $2,737.58 / $3,650.11
| Professional | | $2,571.77 | $2,737.58 | $3,650.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.68 / $1,532.03 / $2,429.80
| Professional | | $1,384.68 | $1,532.03 | $2,429.80 |