- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,841.81 / $3,081.34 / $4,126.80
| Professional | | $2,841.81 | $3,081.34 | $4,126.80 |
- 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 / $2,673.00
| Professional | | $2,272.05 | $2,673.00 | $2,673.00 |
- 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
- $2,673.00 / $2,673.00 / $2,673.00
| Professional | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.31 / $2,432.58 / $3,671.90
| Professional | | $1,119.31 | $2,432.58 | $3,671.90 |