- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.28 / $2,979.28 / $3,724.10
| Professional | | $2,979.28 | $2,979.28 | $3,724.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,340.62 / $2,983.99 / $5,753.88
| Facility | | $2,340.62 | $2,983.99 | $5,753.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,602.00 / $15,341.00 / $15,341.00
| Professional | | $2,602.00 | $15,341.00 | $15,341.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,602.00 / $2,602.00 / $2,602.00
| Facility | | $2,602.00 | $2,602.00 | $2,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.00 / $2,789.85 / $2,861.00
| Professional | | $2,382.00 | $2,789.85 | $2,861.00 |