- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.01 / $10,420.00 / $10,420.00
| Professional | | $2,298.01 | $10,420.00 | $10,420.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,173.20 / $3,173.20 / $3,173.20
| Facility | | $3,173.20 | $3,173.20 | $3,173.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,399.11 / $3,173.20 / $3,516.44
| Professional | | $2,399.11 | $3,173.20 | $3,516.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,560.22 / $3,781.05 / $3,906.95
| Facility | | $1,560.22 | $3,781.05 | $3,906.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.65 / $2,912.77 / $4,201.39
| Professional | | $1,941.65 | $2,912.77 | $4,201.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,966.68 / $3,490.44 / $5,555.55
| Professional | | $2,966.68 | $3,490.44 | $5,555.55 |