- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,259.75 / $3,259.75 / $4,074.69
| Professional | | $3,259.75 | $3,259.75 | $4,074.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,664.00 / $2,664.00 / $5,242.08
| Facility | | $2,664.00 | $2,664.00 | $5,242.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.00 / $3,102.35 / $11,402.46
| Professional | | $2,143.00 | $3,102.35 | $11,402.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.53 / $2,664.00 / $2,664.00
| Facility | | $1,812.53 | $2,664.00 | $2,664.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.53 / $2,664.00 / $3,120.47
| Professional | | $1,812.53 | $2,664.00 | $3,120.47 |