- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.92 / $10,537.60 / $10,537.60
| Professional | | $2,150.92 | $10,537.60 | $10,537.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,372.48 / $3,372.48 / $3,372.48
| Facility | | $3,372.48 | $3,372.48 | $3,372.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.46 / $3,372.48 / $3,643.32
| Professional | | $2,168.46 | $3,372.48 | $3,643.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.42 / $3,552.90 / $3,815.24
| Facility | | $1,659.42 | $3,552.90 | $3,815.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.43 / $3,038.46 / $4,382.70
| Professional | | $2,025.43 | $3,038.46 | $4,382.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.00 / $3,588.97 / $5,882.07
| Professional | | $2,859.00 | $3,588.97 | $5,882.07 |