- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.05 / $3,477.15 / $10,426.00
| Professional | | $2,128.05 | $3,477.15 | $10,426.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,337.78 / $3,337.78 / $3,337.78
| Facility | | $3,337.78 | $3,337.78 | $3,337.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,169.73 / $3,337.78 / $3,604.33
| Professional | | $2,169.73 | $3,337.78 | $3,604.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.42 / $3,534.70 / $3,790.57
| Facility | | $1,642.42 | $3,534.70 | $3,790.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.08 / $3,006.43 / $4,336.50
| Professional | | $2,004.08 | $3,006.43 | $4,336.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,591.05 / $2,591.05 / $2,591.05
| Facility | | $2,591.05 | $2,591.05 | $2,591.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,128.84 / $3,550.03 / $5,821.94
| Professional | | $3,128.84 | $3,550.03 | $5,821.94 |