- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,312.73 / $2,312.73 / $2,312.73
| Professional | | $2,312.73 | $2,312.73 | $2,312.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,481.32 / $3,481.32 / $3,481.32
| Facility | | $3,481.32 | $3,481.32 | $3,481.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,481.32 / $3,481.32 / $3,481.32
| Professional | | $3,481.32 | $3,481.32 | $3,481.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,481.32 / $3,481.32 / $3,481.32
| Facility | | $3,481.32 | $3,481.32 | $3,481.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.62 / $2,696.18 / $4,118.10
| Professional | | $1,419.62 | $2,696.18 | $4,118.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.06 / $2,852.16 / $4,752.74
| Professional | | $2,340.06 | $2,852.16 | $4,752.74 |