- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,338.86 / $2,338.86 / $2,923.57
| Professional | | $2,338.86 | $2,338.86 | $2,923.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,623.18 / $4,623.18 / $4,623.18
| Facility | | $4,623.18 | $4,623.18 | $4,623.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.00 / $7,854.00 / $7,854.00
| Professional | | $2,082.00 | $7,854.00 | $7,854.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,314.21 / $1,314.21 / $2,082.00
| Facility | | $1,314.21 | $1,314.21 | $2,082.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.21 / $2,046.00 / $2,282.78
| Professional | | $1,314.21 | $2,046.00 | $2,282.78 |