- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.98 / $2,663.76 / $4,208.28
| Professional | | $1,857.98 | $2,663.76 | $4,208.28 |
- 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
- $2,272.05 / $2,673.00 / $5,073.75
| Professional | | $2,272.05 | $2,673.00 | $5,073.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,357.92 / $3,357.92 / $3,357.92
| Professional | | $3,357.92 | $3,357.92 | $3,357.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,511.07 / $1,958.79 / $3,317.17
| Professional | | $1,511.07 | $1,958.79 | $3,317.17 |