- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,796.95 / $3,077.97 / $3,329.70
| Professional | | $2,796.95 | $3,077.97 | $3,329.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.96 / $2,272.05 / $2,673.00
| Professional | | $384.96 | $2,272.05 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,062.78 / $3,062.78 / $3,062.78
| Professional | | $3,062.78 | $3,062.78 | $3,062.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.55 / $1,931.84 / $3,671.90
| Professional | | $1,560.55 | $1,931.84 | $3,671.90 |