- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,628.68 / $2,628.68 / $3,285.85
| Professional | | $2,628.68 | $2,628.68 | $3,285.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,212.23 / $2,212.23 / $5,682.77
| Facility | | $2,212.23 | $2,212.23 | $5,682.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,412.00 / $15,682.00 / $15,682.00
| Professional | | $2,412.00 | $15,682.00 | $15,682.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,412.00 / $2,412.00 / $2,412.00
| Facility | | $2,412.00 | $2,412.00 | $2,412.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,208.00 / $2,555.06 / $2,748.72
| Professional | | $2,208.00 | $2,555.06 | $2,748.72 |