- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,765.81 / $2,765.81 / $3,457.26
| Professional | | $2,765.81 | $2,765.81 | $3,457.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,432.86 / $5,432.86 / $5,432.86
| Facility | | $5,432.86 | $5,432.86 | $5,432.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.00 / $13,636.00 / $13,636.00
| Professional | | $2,266.00 | $13,636.00 | $13,636.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,598.50 / $2,319.62 / $3,108.09
| Facility | | $1,598.50 | $2,319.62 | $3,108.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,071.66 / $2,648.27 / $3,159.20
| Professional | | $2,071.66 | $2,648.27 | $3,159.20 |