- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,451.10 / $8,501.54 / $8,501.54
| Professional | | $2,451.10 | $8,501.54 | $8,501.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,952.91 / $3,204.63 / $3,204.63
| Facility | | $1,952.91 | $3,204.63 | $3,204.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,952.91 / $2,606.03 / $3,204.63
| Professional | | $1,952.91 | $2,606.03 | $3,204.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,503.58 / $3,052.03 / $3,204.63
| Facility | | $1,503.58 | $3,052.03 | $3,204.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,952.91 / $2,405.21 / $3,206.96
| Professional | | $1,952.91 | $2,405.21 | $3,206.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.04 / $1,345.45 / $2,133.87
| Professional | | $1,216.04 | $1,345.45 | $2,133.87 |