- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.33 / $2,752.27 / $14,522.00
| Professional | | $2,225.33 | $2,752.27 | $14,522.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,308.41 / $4,308.41 / $4,308.41
| Facility | | $4,308.41 | $4,308.41 | $4,308.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,568.89 / $3,848.24 / $7,652.16
| Professional | | $2,568.89 | $3,848.24 | $7,652.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,536.41 / $3,651.93 / $5,154.24
| Facility | | $2,536.41 | $3,651.93 | $5,154.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.84 / $4,406.34 / $7,342.54
| Professional | | $2,721.84 | $4,406.34 | $7,342.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,726.57 / $4,657.46 / $6,064.82
| Professional | | $3,726.57 | $4,657.46 | $6,064.82 |