- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,222.39 / $10,905.00 / $10,905.00
| Professional | | $2,222.39 | $10,905.00 | $10,905.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,483.43 / $3,483.43 / $3,483.43
| Facility | | $3,483.43 | $3,483.43 | $3,483.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.02 / $3,483.43 / $3,779.51
| Professional | | $2,323.02 | $3,483.43 | $3,779.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,713.48 / $3,726.45 / $3,989.81
| Facility | | $1,713.48 | $3,726.45 | $3,989.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.07 / $3,138.44 / $4,526.89
| Professional | | $2,092.07 | $3,138.44 | $4,526.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,959.58 / $3,715.23 / $6,075.39
| Professional | | $2,959.58 | $3,715.23 | $6,075.39 |