- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,754.23 / $4,365.16
| Professional | | $1,862.09 | $2,754.23 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $5,128.61
| Facility | | $3,235.94 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,754.40 / $8,128.31
| Professional | | $3,235.94 | $5,754.40 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Professional | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,606.93 / $7,585.78
| Professional | | $3,981.07 | $6,606.93 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,884.03 / $3,311.31
| Facility | | $2,754.23 | $2,884.03 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,466.84 / $7,079.46
| Professional | | $2,454.71 | $4,466.84 | $7,079.46 |