- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,399.15 / $3,021.64 / $11,756.30
| Professional | | $2,399.15 | $3,021.64 | $11,756.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,760.52 / $3,760.52 / $3,760.52
| Facility | | $3,760.52 | $3,760.52 | $3,760.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.74 / $3,760.52 / $4,069.93
| Professional | | $2,005.74 | $3,760.52 | $4,069.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,851.10 / $2,409.94 / $3,760.52
| Facility | | $1,851.10 | $2,409.94 | $3,760.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,258.67 / $3,760.52 / $4,887.39
| Professional | | $2,258.67 | $3,760.52 | $4,887.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,190.82 / $3,925.75 / $4,526.93
| Professional | | $3,190.82 | $3,925.75 | $4,526.93 |