- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,226.00 / $2,226.00 / $2,568.46
| Professional | | $2,226.00 | $2,226.00 | $2,568.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,001.39 / $2,823.88
| Professional | | $2,001.39 | $2,001.39 | $2,823.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,741.63 / $2,823.88
| Professional | | $2,001.39 | $2,741.63 | $2,823.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.14 / $3,167.57 / $5,273.40
| Professional | | $1,517.14 | $3,167.57 | $5,273.40 |