- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,415.38 / $3,415.38 / $4,092.01
| Professional | | $3,415.38 | $3,415.38 | $4,092.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,291.83 / $2,171.61 / $2,509.30
| Facility | | $1,291.83 | $2,171.61 | $2,509.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,893.76 / $1,893.76 / $1,893.76
| Professional | | $1,893.76 | $1,893.76 | $1,893.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,214.71 / $1,659.45 / $1,784.34
| Facility | | $1,214.71 | $1,659.45 | $1,784.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,291.83 / $1,878.53 / $2,509.30
| Facility | | $1,291.83 | $1,878.53 | $2,509.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,893.76 / $1,893.76 / $1,893.76
| Professional | | $1,893.76 | $1,893.76 | $1,893.76 |