- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.48 / $2,839.51 / $11,041.00
| Professional | | $2,252.48 | $2,839.51 | $11,041.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,534.43 / $3,534.43 / $3,534.43
| Facility | | $3,534.43 | $3,534.43 | $3,534.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,871.30 / $3,534.43 / $3,727.71
| Professional | | $1,871.30 | $3,534.43 | $3,727.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,668.54 / $2,148.92 / $3,534.43
| Facility | | $1,668.54 | $2,148.92 | $3,534.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,121.51 / $3,534.43 / $4,590.60
| Professional | | $2,121.51 | $3,534.43 | $4,590.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,994.36 / $3,616.00 / $4,077.43
| Professional | | $2,994.36 | $3,616.00 | $4,077.43 |