- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,505.62 / $2,505.62 / $2,505.62
| Professional | | $2,505.62 | $2,505.62 | $2,505.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.51 / $2,119.51 / $2,119.51
| Facility | | $2,119.51 | $2,119.51 | $2,119.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.24 / $2,119.51 / $2,183.10
| Professional | | $1,547.24 | $2,119.51 | $2,183.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $808.65 / $808.65 / $808.65
| Facility | | $808.65 | $808.65 | $808.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,718.30 / $2,793.91 / $4,292.06
| Professional | | $2,718.30 | $2,793.91 | $4,292.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $808.65 / $808.65 / $2,119.51
| Facility | | $808.65 | $808.65 | $2,119.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.24 / $2,183.10 / $3,353.17
| Professional | | $1,547.24 | $2,183.10 | $3,353.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,382.97 / $1,427.51 / $2,736.06
| Professional | | $1,382.97 | $1,427.51 | $2,736.06 |