- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,405.65 / $2,828.21 / $13,884.60
| Professional | | $2,405.65 | $2,828.21 | $13,884.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,213.24 / $4,213.24 / $4,213.24
| Facility | | $4,213.24 | $4,213.24 | $4,213.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.03 / $3,397.72 / $4,213.24
| Professional | | $1,900.03 | $3,397.72 | $4,213.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,086.57 / $2,869.03 / $4,213.24
| Facility | | $2,086.57 | $2,869.03 | $4,213.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.62 / $3,967.24 / $5,508.30
| Professional | | $2,545.62 | $3,967.24 | $5,508.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,321.75 / $4,229.49 / $4,873.91
| Professional | | $3,321.75 | $4,229.49 | $4,873.91 |