- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,671.47 / $12,763.90 / $12,763.90
| Professional | | $2,671.47 | $12,763.90 | $12,763.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,787.34 / $3,787.34 / $3,787.34
| Facility | | $3,787.34 | $3,787.34 | $3,787.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,588.08 / $3,787.34 / $4,074.00
| Professional | | $2,588.08 | $3,787.34 | $4,074.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,860.61 / $4,172.35 / $4,524.27
| Facility | | $1,860.61 | $4,172.35 | $4,524.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,317.55 / $3,476.69 / $5,014.80
| Professional | | $2,317.55 | $3,476.69 | $5,014.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,611.92 / $4,108.14 / $6,676.64
| Professional | | $3,611.92 | $4,108.14 | $6,676.64 |