- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,263.54 / $2,263.54 / $2,829.42
| Professional | | $2,263.54 | $2,263.54 | $2,829.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,405.00 / $3,405.00 / $3,405.00
| Facility | | $3,405.00 | $3,405.00 | $3,405.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,213.23 / $3,652.81 / $9,073.53
| Professional | | $3,213.23 | $3,652.81 | $9,073.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,405.00 / $4,568.76 / $5,096.70
| Facility | | $3,405.00 | $4,568.76 | $5,096.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,213.23 / $5,096.70 / $9,073.53
| Professional | | $3,213.23 | $5,096.70 | $9,073.53 |