- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $2,951.21
| Professional | | $1,819.70 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,388.44 / $3,388.44
| Facility | | $3,235.94 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,388.44
| Professional | | $2,454.71 | $2,454.71 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,168.69 / $5,370.32
| Professional | | $3,467.37 | $4,168.69 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $3,235.94
| Facility | | $2,398.83 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,311.31 / $9,332.54
| Professional | | $1,548.82 | $3,311.31 | $9,332.54 |