- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,843.00 / $2,843.00 / $2,843.00
| Professional | | $2,843.00 | $2,843.00 | $2,843.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $442.84 / $671.88 / $1,178.08
| Facility | | $442.84 | $671.88 | $1,178.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $720.78 / $1,438.00 / $2,720.00
| Facility | | $720.78 | $1,438.00 | $2,720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,988.00 / $2,988.00 / $3,335.23
| Professional | | $2,988.00 | $2,988.00 | $3,335.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $563.00 / $1,749.00 / $2,883.00
| Facility | | $563.00 | $1,749.00 | $2,883.00 |