- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.44 / $2,112.02 / $11,148.60
| Professional | | $1,742.44 | $2,112.02 | $11,148.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,427.69 / $3,427.69 / $3,427.69
| Facility | | $3,427.69 | $3,427.69 | $3,427.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,971.62 / $3,427.69 / $6,057.00
| Professional | | $1,971.62 | $3,427.69 | $6,057.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,060.62 / $2,643.64 / $3,827.26
| Facility | | $2,060.62 | $2,643.64 | $3,827.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.86 / $3,492.94 / $5,820.48
| Professional | | $2,125.86 | $3,492.94 | $5,820.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,949.71 / $3,530.88 / $4,393.20
| Professional | | $2,949.71 | $3,530.88 | $4,393.20 |