- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.53 / $2,973.72 / $11,576.90
| Professional | | $2,017.53 | $2,973.72 | $11,576.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,702.68 / $3,702.68 / $3,702.68
| Facility | | $3,702.68 | $3,702.68 | $3,702.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.49 / $3,702.68 / $4,009.40
| Professional | | $1,894.49 | $3,702.68 | $4,009.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,821.92 / $2,323.26 / $3,702.68
| Facility | | $1,821.92 | $2,323.26 | $3,702.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.03 / $3,702.68 / $4,814.60
| Professional | | $2,225.03 | $3,702.68 | $4,814.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,144.77 / $3,829.16 / $4,829.52
| Professional | | $3,144.77 | $3,829.16 | $4,829.52 |