- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.04 / $2,017.67 / $3,377.78
| Professional | | $1,542.04 | $2,017.67 | $3,377.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,254.90 / $2,254.90 / $2,254.90
| Facility | | $2,254.90 | $2,254.90 | $2,254.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.67 / $2,254.90 / $3,993.75
| Professional | | $1,916.67 | $2,254.90 | $3,993.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,571.60 / $2,571.60 / $2,571.60
| Professional | | $2,571.60 | $2,571.60 | $2,571.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.80 / $1,604.77 / $2,905.34
| Professional | | $1,285.80 | $1,604.77 | $2,905.34 |