- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,413.57 / $11,511.80 / $11,511.80
| Professional | | $2,413.57 | $11,511.80 | $11,511.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,426.64 / $3,426.64 / $3,426.64
| Facility | | $3,426.64 | $3,426.64 | $3,426.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.26 / $3,426.64 / $3,674.75
| Professional | | $2,282.26 | $3,426.64 | $3,674.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,684.43 / $3,750.50 / $4,073.30
| Facility | | $1,684.43 | $3,750.50 | $4,073.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,094.66 / $3,142.32 / $4,532.50
| Professional | | $2,094.66 | $3,142.32 | $4,532.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,943.13 / $3,694.58 / $6,039.33
| Professional | | $2,943.13 | $3,694.58 | $6,039.33 |