- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,520.82 / $8,743.32 / $8,743.32
| Professional | | $2,520.82 | $8,743.32 | $8,743.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,424.68 / $2,576.32 / $2,576.32
| Facility | | $1,424.68 | $2,576.32 | $2,576.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.68 / $2,576.32 / $2,576.32
| Professional | | $1,424.68 | $2,576.32 | $2,576.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.15 / $2,453.64 / $2,576.32
| Facility | | $1,271.15 | $2,453.64 | $2,576.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.64 / $1,976.49 / $2,821.69
| Professional | | $1,933.64 | $1,976.49 | $2,821.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.06 / $1,137.47 / $1,804.01
| Professional | | $1,028.06 | $1,137.47 | $1,804.01 |