- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.19 / $2,856.25 / $10,736.80
| Professional | | $2,190.19 | $2,856.25 | $10,736.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,242.08 / $3,242.08 / $3,242.08
| Facility | | $3,242.08 | $3,242.08 | $3,242.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.46 / $3,242.08 / $3,409.94
| Professional | | $1,844.46 | $3,242.08 | $3,409.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,603.26 / $2,204.48 / $3,284.42
| Facility | | $1,603.26 | $2,204.48 | $3,284.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.53 / $3,242.08 / $4,257.39
| Professional | | $1,967.53 | $3,242.08 | $4,257.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,804.95 / $3,401.76 / $5,132.49
| Professional | | $2,804.95 | $3,401.76 | $5,132.49 |