- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,435.77 / $2,746.11 / $14,426.40
| Professional | | $2,435.77 | $2,746.11 | $14,426.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,290.00 / $4,290.00 / $4,290.00
| Facility | | $4,290.00 | $4,290.00 | $4,290.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,656.30 / $4,290.00 / $7,886.68
| Professional | | $2,656.30 | $4,290.00 | $7,886.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,627.86 / $3,870.12 / $5,265.56
| Facility | | $2,627.86 | $3,870.12 | $5,265.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.61 / $4,355.66 / $7,258.08
| Professional | | $2,711.61 | $4,355.66 | $7,258.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,914.26 / $4,692.21 / $6,370.27
| Professional | | $3,914.26 | $4,692.21 | $6,370.27 |