- 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
- $5,091.57 / $5,091.57 / $5,091.57
| Facility | | $5,091.57 | $5,091.57 | $5,091.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.00 / $14,233.00 / $14,233.00
| Professional | | $2,231.00 | $14,233.00 | $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
- $1,938.88 / $2,458.63 / $3,045.23
| Professional | | $1,938.88 | $2,458.63 | $3,045.23 |