- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,553.73 / $3,493.26 / $4,760.96
| Professional | | $2,553.73 | $3,493.26 | $4,760.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $4,696.49
| Facility | | $2,900.00 | $2,900.00 | $4,696.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.00 / $2,900.00 / $2,987.00
| Professional | | $2,465.00 | $2,900.00 | $2,987.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,230.41 / $4,230.41 / $4,230.41
| Facility | | $4,230.41 | $4,230.41 | $4,230.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,064.47 / $4,864.24 / $5,723.45
| Professional | | $3,064.47 | $4,864.24 | $5,723.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,131.59 / $4,697.39 / $5,219.33
| Professional | | $3,131.59 | $4,697.39 | $5,219.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,294.04 / $2,877.62 / $4,134.60
| Professional | | $2,294.04 | $2,877.62 | $4,134.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,219.33 / $5,219.33 / $5,219.33
| Professional | | $5,219.33 | $5,219.33 | $5,219.33 |