- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,735.88 / $3,110.40 / $3,110.40
| Professional | | $2,735.88 | $3,110.40 | $3,110.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,529.91 / $1,529.91 / $1,529.91
| Facility | | $1,529.91 | $1,529.91 | $1,529.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,365.59 / $3,764.09 / $5,611.55
| Professional | | $3,365.59 | $3,764.09 | $5,611.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.34 / $1,907.61 / $3,494.28
| Professional | | $1,348.34 | $1,907.61 | $3,494.28 |