- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.10 / $2,737.32 / $11,734.00
| Professional | | $1,740.10 | $2,737.32 | $11,734.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,054.39 / $3,054.39 / $3,054.39
| Facility | | $3,054.39 | $3,054.39 | $3,054.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.56 / $3,419.30 / $4,555.47
| Professional | | $1,190.56 | $3,419.30 | $4,555.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,054.39 / $3,054.39 / $3,054.39
| Facility | | $3,054.39 | $3,054.39 | $3,054.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.56 / $2,830.76 / $4,555.47
| Professional | | $1,190.56 | $2,830.76 | $4,555.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.11 / $2,485.86 / $8,211.95
| Professional | | $797.11 | $2,485.86 | $8,211.95 |