- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,974.60 / $2,974.60 / $3,718.25
| Professional | | $2,974.60 | $2,974.60 | $3,718.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,763.66 / $4,870.85 / $4,870.85
| Facility | | $3,763.66 | $4,870.85 | $4,870.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,003.00 / $10,396.14 / $10,396.14
| Professional | | $2,003.00 | $10,396.14 | $10,396.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,535.16 / $1,535.16 / $2,696.68
| Facility | | $1,535.16 | $1,535.16 | $2,696.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.57 / $2,482.00 / $2,854.82
| Professional | | $1,989.57 | $2,482.00 | $2,854.82 |