- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,616.59 / $11,766.80 / $11,766.80
| Professional | | $2,616.59 | $11,766.80 | $11,766.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,591.74 / $3,591.74 / $3,591.74
| Facility | | $3,591.74 | $3,591.74 | $3,591.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.22 / $3,591.74 / $3,591.74
| Professional | | $2,823.22 | $3,591.74 | $3,591.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,591.74 / $4,597.45 / $4,956.27
| Facility | | $3,591.74 | $4,597.45 | $4,956.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,211.12 / $3,132.48 / $4,784.50
| Professional | | $2,211.12 | $3,132.48 | $4,784.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,837.43 / $2,837.43 / $2,837.43
| Facility | | $2,837.43 | $2,837.43 | $2,837.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,532.89 / $4,076.41 / $6,292.78
| Professional | | $3,532.89 | $4,076.41 | $6,292.78 |