- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,611.16 / $3,664.16 / $3,664.16
| Professional | | $2,611.16 | $3,664.16 | $3,664.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.51 / $3,248.38 / $3,248.38
| Facility | | $2,630.51 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.13 / $3,248.38 / $7,654.69
| Professional | | $453.13 | $3,248.38 | $7,654.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,763.65 / $3,664.16 / $4,610.85
| Facility | | $1,763.65 | $3,664.16 | $4,610.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,952.00 / $3,952.00 / $3,952.00
| Professional | | $3,952.00 | $3,952.00 | $3,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.66 / $2,659.92 / $4,802.20
| Professional | | $1,763.66 | $2,659.92 | $4,802.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,844.10 / $28,730.61 / $28,730.61
| Facility | | $4,844.10 | $28,730.61 | $28,730.61 |