- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,186.40 / $2,851.17 / $10,717.50
| Professional | | $2,186.40 | $2,851.17 | $10,717.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.77 / $3,235.77 / $3,235.77
| Facility | | $3,235.77 | $3,235.77 | $3,235.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.59 / $3,235.77 / $3,521.10
| Professional | | $1,767.59 | $3,235.77 | $3,521.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,599.90 / $2,199.86 / $3,295.77
| Facility | | $1,599.90 | $2,199.86 | $3,295.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.97 / $3,235.77 / $4,249.70
| Professional | | $1,963.97 | $3,235.77 | $4,249.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,547.55 / $2,547.55 / $2,547.55
| Facility | | $2,547.55 | $2,547.55 | $2,547.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,904.96 / $3,403.47 / $3,813.11
| Professional | | $2,904.96 | $3,403.47 | $3,813.11 |