- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.46 / $2,823.46 / $3,529.32
| Professional | | $2,823.46 | $2,823.46 | $3,529.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,149.46 / $2,149.46 / $5,184.27
| Facility | | $2,149.46 | $2,149.46 | $5,184.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,381.00 / $13,636.00 / $13,636.00
| Professional | | $2,381.00 | $13,636.00 | $13,636.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,381.00 / $2,381.00 / $2,381.00
| Facility | | $2,381.00 | $2,381.00 | $2,381.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,179.00 / $2,643.00 / $2,712.85
| Professional | | $2,179.00 | $2,643.00 | $2,712.85 |