- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,974.60 / $2,974.60 / $3,718.25
| Professional | | $2,974.60 | $2,974.60 | $3,718.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,482.00 / $2,482.00 / $5,000.00
| Facility | | $2,482.00 | $2,482.00 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,003.00 / $2,751.70 / $10,396.14
| Professional | | $2,003.00 | $2,751.70 | $10,396.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,535.16 / $2,482.00 / $2,482.00
| Facility | | $1,535.16 | $2,482.00 | $2,482.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.16 / $2,482.00 / $2,854.82
| Professional | | $1,535.16 | $2,482.00 | $2,854.82 |