- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,894.62 / $13,508.30 / $13,508.30
| Professional | | $3,894.62 | $13,508.30 | $13,508.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.52 / $4,489.93 / $4,489.93
| Facility | | $3,600.52 | $4,489.93 | $4,489.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,600.52 / $4,489.93 / $4,489.93
| Professional | | $3,600.52 | $4,489.93 | $4,489.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,258.80 / $4,276.13 / $4,489.93
| Facility | | $2,258.80 | $4,276.13 | $4,489.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,369.90 / $3,600.52 / $4,493.20
| Professional | | $3,369.90 | $3,600.52 | $4,493.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.83 / $2,021.25 / $3,205.69
| Professional | | $1,826.83 | $2,021.25 | $3,205.69 |