- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.48 / $2,845.09 / $10,751.50
| Professional | | $2,155.48 | $2,845.09 | $10,751.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,206.85 / $3,206.85 / $3,206.85
| Facility | | $3,206.85 | $3,206.85 | $3,206.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,746.00 / $3,206.85 / $3,419.25
| Professional | | $1,746.00 | $3,206.85 | $3,419.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,589.06 / $2,184.94 / $3,206.85
| Facility | | $1,589.06 | $2,184.94 | $3,206.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.15 / $3,206.85 / $4,213.30
| Professional | | $1,947.15 | $3,206.85 | $4,213.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,527.94 / $2,527.94 / $2,527.94
| Facility | | $2,527.94 | $2,527.94 | $2,527.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,783.34 / $3,370.08 / $3,790.08
| Professional | | $2,783.34 | $3,370.08 | $3,790.08 |