- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.00 / $11,806.40 / $11,806.40
| Professional | | $2,411.00 | $11,806.40 | $11,806.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,774.19 / $3,774.19 / $3,774.19
| Facility | | $3,774.19 | $3,774.19 | $3,774.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.96 / $3,774.19 / $4,089.13
| Professional | | $2,456.96 | $3,774.19 | $4,089.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.46 / $4,015.05 / $4,301.00
| Facility | | $1,857.46 | $4,015.05 | $4,301.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,268.71 / $3,403.41 / $4,909.10
| Professional | | $2,268.71 | $3,403.41 | $4,909.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,207.75 / $3,958.50 / $6,586.92
| Professional | | $3,207.75 | $3,958.50 | $6,586.92 |