- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,514.71 / $2,026.86 / $3,355.42
| Professional | | $1,514.71 | $2,026.86 | $3,355.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $2,592.00
| Facility | | $2,592.00 | $2,592.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,203.19 / $2,592.00 / $3,993.75
| Professional | | $2,203.19 | $2,592.00 | $3,993.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,555.44 / $2,555.44 / $2,555.44
| Professional | | $2,555.44 | $2,555.44 | $2,555.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.72 / $1,594.76 / $2,819.42
| Professional | | $1,277.72 | $1,594.76 | $2,819.42 |