- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.55 / $2,582.21 / $12,668.80
| Professional | | $2,128.55 | $2,582.21 | $12,668.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,037.62 / $4,037.62 / $4,037.62
| Facility | | $4,037.62 | $4,037.62 | $4,037.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,296.62 / $4,037.62 / $4,143.26
| Professional | | $2,296.62 | $4,037.62 | $4,143.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,969.80 / $4,037.62 / $4,262.42
| Facility | | $1,969.80 | $4,037.62 | $4,262.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,471.54 / $3,707.69 / $5,348.00
| Professional | | $2,471.54 | $3,707.69 | $5,348.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,205.36 / $4,131.33 / $7,099.36
| Professional | | $3,205.36 | $4,131.33 | $7,099.36 |