- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,455.81 / $11,044.10 / $11,044.10
| Professional | | $2,455.81 | $11,044.10 | $11,044.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,371.43 / $3,371.43 / $3,371.43
| Facility | | $3,371.43 | $3,371.43 | $3,371.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,653.38 / $3,371.43 / $3,371.43
| Professional | | $2,653.38 | $3,371.43 | $3,371.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,371.43 / $4,274.39 / $4,387.64
| Facility | | $3,371.43 | $4,274.39 | $4,387.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.25 / $2,939.99 / $4,490.50
| Professional | | $2,075.25 | $2,939.99 | $4,490.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,315.52 / $3,825.60 / $5,904.27
| Professional | | $3,315.52 | $3,825.60 | $5,904.27 |