- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,584.27 / $2,584.27 / $3,230.34
| Professional | | $2,584.27 | $2,584.27 | $3,230.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,009.86 / $2,626.98 / $5,062.97
| Facility | | $2,009.86 | $2,626.98 | $5,062.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,256.00 / $8,345.00 / $8,345.00
| Professional | | $2,256.00 | $8,345.00 | $8,345.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,451.94 / $1,451.94 / $2,256.00
| Facility | | $1,451.94 | $1,451.94 | $2,256.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.94 / $2,257.00 / $2,520.19
| Professional | | $1,451.94 | $2,257.00 | $2,520.19 |