- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.26 / $2,117.26 / $2,443.00
| Professional | | $2,117.26 | $2,117.26 | $2,443.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,381.07 / $2,381.07 / $2,381.07
| Facility | | $2,381.07 | $2,381.07 | $2,381.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.18 / $2,381.07 / $2,452.50
| Professional | | $1,738.18 | $2,381.07 | $2,452.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,381.07 / $2,381.07 / $2,381.07
| Facility | | $2,381.07 | $2,381.07 | $2,381.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.18 / $2,381.07 / $2,452.50
| Professional | | $1,738.18 | $2,381.07 | $2,452.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.72 / $2,430.84 / $4,399.27
| Professional | | $1,286.72 | $2,430.84 | $4,399.27 |