- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.96 / $10,503.00 / $10,503.00
| Professional | | $2,334.96 | $10,503.00 | $10,503.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,207.38 / $3,207.38 / $3,207.38
| Facility | | $3,207.38 | $3,207.38 | $3,207.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,526.92 / $3,207.38 / $3,207.38
| Professional | | $2,526.92 | $3,207.38 | $3,207.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,207.38 / $4,094.35 / $4,421.81
| Facility | | $3,207.38 | $4,094.35 | $4,421.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,973.35 / $2,795.63 / $4,270.00
| Professional | | $1,973.35 | $2,795.63 | $4,270.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,152.24 / $3,637.20 / $5,614.73
| Professional | | $3,152.24 | $3,637.20 | $5,614.73 |