- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.42 / $1,972.42 / $3,454.24
| Professional | | $1,972.42 | $1,972.42 | $3,454.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,852.38 / $3,852.38 / $3,852.38
| Facility | | $3,852.38 | $3,852.38 | $3,852.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,852.38 / $3,852.38 / $3,852.38
| Professional | | $3,852.38 | $3,852.38 | $3,852.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.10 / $2,481.10 / $4,339.32
| Facility | | $2,481.10 | $2,481.10 | $4,339.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.20 / $1,811.20 / $2,481.10
| Professional | | $1,811.20 | $1,811.20 | $2,481.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,486.02 / $2,600.65 / $2,600.65
| Facility | | $1,486.02 | $2,600.65 | $2,600.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.74 / $1,968.04 / $3,032.69
| Professional | | $1,778.74 | $1,968.04 | $3,032.69 |