- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.92 / $2,878.19 / $3,570.00
| Professional | | $2,406.92 | $2,878.19 | $3,570.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,425.98 / $1,731.86 / $2,072.46
| Facility | | $1,425.98 | $1,731.86 | $2,072.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,384.12 / $3,384.12 / $3,384.12
| Facility | | $3,384.12 | $3,384.12 | $3,384.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,384.12 / $3,384.12 / $3,384.12
| Professional | | $3,384.12 | $3,384.12 | $3,384.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $4,200.00
| Professional | | $4,200.00 | $4,200.00 | $4,200.00 |