- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,251.31 / $10,301.00 / $10,301.00
| Professional | | $2,251.31 | $10,301.00 | $10,301.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,130.61 / $3,130.61 / $3,130.61
| Facility | | $3,130.61 | $3,130.61 | $3,130.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,526.81 / $3,130.61 / $3,130.61
| Professional | | $2,526.81 | $3,130.61 | $3,130.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,130.61 / $3,497.65 / $3,630.55
| Facility | | $3,130.61 | $3,497.65 | $3,630.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.03 / $2,717.26 / $4,150.30
| Professional | | $1,918.03 | $2,717.26 | $4,150.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.19 / $3,457.40 / $5,487.10
| Professional | | $2,754.19 | $3,457.40 | $5,487.10 |