- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.24 / $2,106.75 / $3,710.38
| Professional | | $1,610.24 | $2,106.75 | $3,710.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,270.91 / $2,671.66 / $4,515.00
| Professional | | $2,270.91 | $2,671.66 | $4,515.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,722.64 / $2,722.64 / $2,722.64
| Professional | | $2,722.64 | $2,722.64 | $2,722.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.32 / $1,588.21 / $3,133.16
| Professional | | $1,361.32 | $1,588.21 | $3,133.16 |