- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.13 / $2,527.13 / $3,158.91
| Professional | | $2,527.13 | $2,527.13 | $3,158.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,874.42 / $3,874.42 / $3,874.42
| Facility | | $3,874.42 | $3,874.42 | $3,874.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.00 / $2,691.00 / $6,884.28
| Professional | | $2,691.00 | $2,691.00 | $6,884.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.00 / $2,691.00 / $2,691.00
| Facility | | $2,691.00 | $2,691.00 | $2,691.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,430.04 / $2,711.51 / $4,538.91
| Professional | | $2,430.04 | $2,711.51 | $4,538.91 |