- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.23 / $2,836.39 / $14,905.00
| Professional | | $2,404.23 | $2,836.39 | $14,905.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.08 / $4,536.08 / $4,536.08
| Facility | | $4,536.08 | $4,536.08 | $4,536.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,707.24 / $4,536.08 / $8,186.77
| Professional | | $2,707.24 | $4,536.08 | $8,186.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,790.45 / $3,769.91 / $5,211.17
| Facility | | $2,790.45 | $3,769.91 | $5,211.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,851.77 / $4,650.60 / $7,749.56
| Professional | | $2,851.77 | $4,650.60 | $7,749.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,969.14 / $4,847.35 / $6,095.54
| Professional | | $3,969.14 | $4,847.35 | $6,095.54 |