- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,206.00 / $11,130.70 / $11,130.70
| Professional | | $2,206.00 | $11,130.70 | $11,130.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,356.71 / $3,356.71 / $3,356.71
| Facility | | $3,356.71 | $3,356.71 | $3,356.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.17 / $3,356.71 / $3,597.34
| Professional | | $2,404.17 | $3,356.71 | $3,597.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,645.46 / $3,749.20 / $4,033.45
| Facility | | $1,645.46 | $3,749.20 | $4,033.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,046.78 / $3,070.49 / $4,428.89
| Professional | | $2,046.78 | $3,070.49 | $4,428.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,941.68 / $3,590.15 / $5,907.98
| Professional | | $2,941.68 | $3,590.15 | $5,907.98 |