- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,276.89 / $3,276.89 / $4,096.12
| Professional | | $3,276.89 | $3,276.89 | $4,096.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,537.00 / $2,537.00 / $5,201.28
| Facility | | $2,537.00 | $2,537.00 | $5,201.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.00 / $2,752.93 / $11,171.88
| Professional | | $2,091.00 | $2,752.93 | $11,171.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,615.59 / $2,537.00 / $2,537.00
| Facility | | $1,615.59 | $2,537.00 | $2,537.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.59 / $2,406.60 / $2,756.54
| Professional | | $1,615.59 | $2,406.60 | $2,756.54 |