- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,149.09 / $2,616.25 / $11,967.00
| Professional | | $2,149.09 | $2,616.25 | $11,967.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,640.64 / $3,640.64 / $3,640.64
| Facility | | $3,640.64 | $3,640.64 | $3,640.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,720.16 / $3,640.64 / $3,640.64
| Professional | | $2,720.16 | $3,640.64 | $3,640.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,640.64 / $4,057.30 / $4,212.45
| Facility | | $3,640.64 | $4,057.30 | $4,212.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,229.56 / $3,158.60 / $4,824.39
| Professional | | $2,229.56 | $3,158.60 | $4,824.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,198.81 / $4,057.30 / $6,376.93
| Professional | | $3,198.81 | $4,057.30 | $6,376.93 |