- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.00 / $1,918.00 / $2,843.00
| Professional | | $1,918.00 | $1,918.00 | $2,843.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,377.98 / $2,090.69 / $3,665.86
| Facility | | $1,377.98 | $2,090.69 | $3,665.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,003.52 / $3,003.52 / $6,690.92
| Professional | | $3,003.52 | $3,003.52 | $6,690.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $796.00 / $3,378.00 / $8,152.00
| Facility | | $796.00 | $3,378.00 | $8,152.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $796.00 / $3,500.00 / $8,152.00
| Facility | | $796.00 | $3,500.00 | $8,152.00 |