- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,596.73 / $2,596.73 / $3,245.93
| Professional | | $2,596.73 | $2,596.73 | $3,245.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,704.23 / $5,091.57
| Facility | | $55.00 | $2,704.23 | $5,091.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.00 / $2,900.82 / $14,233.00
| Professional | | $2,231.00 | $2,900.82 | $14,233.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,496.05 / $2,231.00 / $3,045.23
| Facility | | $1,496.05 | $2,231.00 | $3,045.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.78 / $2,494.23 / $3,306.79
| Professional | | $1,452.78 | $2,494.23 | $3,306.79 |