- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,462.73 / $2,462.73 / $3,078.42
| Professional | | $2,462.73 | $2,462.73 | $3,078.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,768.05 / $4,768.05 / $4,768.05
| Facility | | $4,768.05 | $4,768.05 | $4,768.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.00 / $8,345.00 / $8,345.00
| Professional | | $2,143.00 | $8,345.00 | $8,345.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,383.95 / $1,383.95 / $2,143.00
| Facility | | $1,383.95 | $1,383.95 | $2,143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.95 / $1,962.00 / $2,411.67
| Professional | | $1,383.95 | $1,962.00 | $2,411.67 |