- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,574.82 / $12,399.10 / $12,399.10
| Professional | | $3,574.82 | $12,399.10 | $12,399.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,561.34 / $3,421.48 / $3,421.48
| Facility | | $2,561.34 | $3,421.48 | $3,421.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,561.34 / $2,782.37 / $3,421.48
| Professional | | $2,561.34 | $2,782.37 | $3,421.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,796.94 / $3,258.55 / $3,421.48
| Facility | | $1,796.94 | $3,258.55 | $3,421.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,561.34 / $2,567.96 / $3,747.33
| Professional | | $2,561.34 | $2,567.96 | $3,747.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.29 / $1,607.95 / $2,550.19
| Professional | | $1,453.29 | $1,607.95 | $2,550.19 |