- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.44 / $10,837.60 / $10,837.60
| Professional | | $2,266.44 | $10,837.60 | $10,837.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,216.32 / $3,216.32 / $3,216.32
| Facility | | $3,216.32 | $3,216.32 | $3,216.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,164.08 / $3,216.32 / $3,453.01
| Professional | | $2,164.08 | $3,216.32 | $3,453.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,580.13 / $3,515.85 / $3,827.89
| Facility | | $1,580.13 | $3,515.85 | $3,827.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.82 / $2,953.54 / $4,260.20
| Professional | | $1,968.82 | $2,953.54 | $4,260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,765.00 / $3,470.97 / $5,672.08
| Professional | | $2,765.00 | $3,470.97 | $5,672.08 |