- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.04 / $2,511.04 / $3,138.81
| Professional | | $2,511.04 | $2,511.04 | $3,138.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,154.00 / $5,154.00 / $5,154.00
| Facility | | $5,154.00 | $5,154.00 | $5,154.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.00 / $9,793.45 / $9,793.45
| Professional | | $1,967.00 | $9,793.45 | $9,793.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,134.90 / $1,425.43 / $2,204.57
| Facility | | $1,134.90 | $1,425.43 | $2,204.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.71 / $1,939.04 / $2,215.69
| Professional | | $597.71 | $1,939.04 | $2,215.69 |