- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,638.40 / $3,638.40 / $4,548.00
| Professional | | $3,638.40 | $3,638.40 | $4,548.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,890.00 / $2,890.00 / $6,131.82
| Facility | | $2,890.00 | $2,890.00 | $6,131.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,336.00 / $2,890.00 / $9,115.20
| Professional | | $2,336.00 | $2,890.00 | $9,115.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,681.26 / $2,857.13 / $2,890.00
| Facility | | $1,681.26 | $2,857.13 | $2,890.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.26 / $2,771.31 / $3,397.18
| Professional | | $1,681.26 | $2,771.31 | $3,397.18 |