- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,485.33 / $2,485.33 / $3,106.66
| Professional | | $2,485.33 | $2,485.33 | $3,106.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.97 / $4,466.45 / $4,466.45
| Facility | | $3,162.97 | $4,466.45 | $4,466.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.00 / $7,309.74 / $7,309.74
| Professional | | $1,632.00 | $7,309.74 | $7,309.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,374.31 / $1,374.31 / $1,997.00
| Facility | | $1,374.31 | $1,374.31 | $1,997.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.31 / $1,828.00 / $2,366.21
| Professional | | $1,374.31 | $1,828.00 | $2,366.21 |