- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,926.75 / $2,521.14 / $4,364.62
| Professional | | $1,926.75 | $2,521.14 | $4,364.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Facility | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,847.37 / $3,349.85 / $5,261.25
| Professional | | $2,847.37 | $3,349.85 | $5,261.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,482.64 / $3,482.64 / $3,482.64
| Professional | | $3,482.64 | $3,482.64 | $3,482.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.51 / $2,284.67 / $3,682.32
| Professional | | $1,618.51 | $2,284.67 | $3,682.32 |