- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,873.00 / $2,288.55 / $11,227.10
| Professional | | $1,873.00 | $2,288.55 | $11,227.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,584.38 / $3,584.38 / $3,584.38
| Facility | | $3,584.38 | $3,584.38 | $3,584.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,351.19 / $3,584.38 / $3,893.58
| Professional | | $2,351.19 | $3,584.38 | $3,893.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,763.19 / $3,848.65 / $4,115.68
| Facility | | $1,763.19 | $3,848.65 | $4,115.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,153.86 / $3,231.13 / $4,660.60
| Professional | | $2,153.86 | $3,231.13 | $4,660.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,048.41 / $3,789.43 / $6,252.08
| Professional | | $3,048.41 | $3,789.43 | $6,252.08 |