- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,454.71 / $3,235.94
| Professional | | $1,737.80 | $2,454.71 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,019.95
| Professional | | $2,187.76 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,890.45 / $5,248.07
| Professional | | $3,090.30 | $3,890.45 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $3,162.28
| Facility | | $2,630.27 | $2,630.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,019.95 / $8,317.64
| Professional | | $1,380.38 | $3,019.95 | $8,317.64 |