- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,130.03 / $2,457.42 / $12,037.50
| Professional | | $2,130.03 | $2,457.42 | $12,037.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,849.91 / $3,849.91 / $3,849.91
| Facility | | $3,849.91 | $3,849.91 | $3,849.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,514.96 / $3,849.91 / $4,166.54
| Professional | | $2,514.96 | $3,849.91 | $4,166.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.13 / $4,110.60 / $4,398.41
| Facility | | $1,895.13 | $4,110.60 | $4,398.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,313.03 / $3,469.90 / $5,005.00
| Professional | | $2,313.03 | $3,469.90 | $5,005.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,268.37 / $4,047.35 / $6,716.42
| Professional | | $3,268.37 | $4,047.35 | $6,716.42 |