- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,240.22 / $14,707.00 / $14,707.00
| Professional | | $4,240.22 | $14,707.00 | $14,707.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,297.39 / $4,014.13 / $4,014.13
| Facility | | $3,297.39 | $4,014.13 | $4,014.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,264.33 / $4,014.13 / $4,014.13
| Professional | | $3,264.33 | $4,014.13 | $4,014.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,131.40 / $3,822.98 / $4,014.13
| Facility | | $2,131.40 | $3,822.98 | $4,014.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,012.79 / $3,297.39 / $4,396.43
| Professional | | $3,012.79 | $3,297.39 | $4,396.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.80 / $1,907.24 / $3,024.88
| Professional | | $1,723.80 | $1,907.24 | $3,024.88 |