- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.85 / $2,784.11 / $14,671.40
| Professional | | $2,382.85 | $2,784.11 | $14,671.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,482.45 / $4,482.45 / $4,482.45
| Facility | | $4,482.45 | $4,482.45 | $4,482.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,632.10 / $4,462.58 / $8,093.53
| Professional | | $2,632.10 | $4,462.58 | $8,093.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,010.00 / $3,711.42 / $5,144.12
| Facility | | $2,010.00 | $3,711.42 | $5,144.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,813.05 / $4,583.20 / $7,637.25
| Professional | | $2,813.05 | $4,583.20 | $7,637.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,834.12 / $4,792.31 / $6,016.14
| Professional | | $3,834.12 | $4,792.31 | $6,016.14 |