- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,585.05 / $2,585.05 / $3,231.32
| Professional | | $2,585.05 | $2,585.05 | $3,231.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,060.88 / $5,060.88 / $5,060.88
| Facility | | $5,060.88 | $5,060.88 | $5,060.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,254.00 / $8,345.00 / $8,345.00
| Professional | | $2,254.00 | $8,345.00 | $8,345.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.34 / $1,452.34 / $2,254.00
| Facility | | $1,452.34 | $1,452.34 | $2,254.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.34 / $2,257.00 / $2,515.21
| Professional | | $1,452.34 | $2,257.00 | $2,515.21 |