- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.43 / $2,675.43 / $3,344.29
| Professional | | $2,675.43 | $2,675.43 | $3,344.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.51 / $2,714.52 / $5,204.25
| Facility | | $2,116.51 | $2,714.52 | $5,204.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,318.00 / $8,781.00 / $8,781.00
| Professional | | $2,318.00 | $8,781.00 | $8,781.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,504.30 / $1,504.30 / $2,318.00
| Facility | | $1,504.30 | $1,504.30 | $2,318.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,504.30 / $2,122.00 / $2,606.53
| Professional | | $1,504.30 | $2,122.00 | $2,606.53 |