- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,259.75 / $3,259.75 / $4,074.69
| Professional | | $3,259.75 | $3,259.75 | $4,074.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,126.96 / $5,242.08 / $5,242.08
| Facility | | $4,126.96 | $5,242.08 | $5,242.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.00 / $11,402.46 / $11,402.46
| Professional | | $2,143.00 | $11,402.46 | $11,402.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.53 / $1,812.53 / $2,895.09
| Facility | | $1,812.53 | $1,812.53 | $2,895.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.00 / $2,664.00 / $3,120.47
| Professional | | $2,143.00 | $2,664.00 | $3,120.47 |