- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,886.51 / $2,886.51 / $3,608.14
| Professional | | $2,886.51 | $2,886.51 | $3,608.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.03 / $3,655.03 / $3,655.03
| Facility | | $3,655.03 | $3,655.03 | $3,655.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.00 / $7,747.35 / $7,747.35
| Professional | | $1,248.00 | $7,747.35 | $7,747.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,248.00 / $1,883.20 / $2,365.30
| Facility | | $1,248.00 | $1,883.20 | $2,365.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.00 / $2,365.30 / $3,264.82
| Professional | | $909.00 | $2,365.30 | $3,264.82 |