- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,977.60 / $2,587.64 / $4,643.18
| Professional | | $1,977.60 | $2,587.64 | $4,643.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,621.85
| Facility | | $3,621.85 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,078.57 / $3,621.85 / $5,707.50
| Professional | | $3,078.57 | $3,621.85 | $5,707.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.75 / $351.75 / $3,704.40
| Professional | | $351.75 | $351.75 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,696.61 / $2,134.80 / $3,732.76
| Professional | | $1,696.61 | $2,134.80 | $3,732.76 |