- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,131.98 / $3,131.98 / $3,914.98
| Professional | | $3,131.98 | $3,131.98 | $3,914.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,802.71 / $5,219.25 / $5,219.25
| Facility | | $3,802.71 | $5,219.25 | $5,219.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.00 / $7,846.44 / $7,846.44
| Professional | | $2,012.00 | $7,846.44 | $7,846.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,511.50 / $1,511.50 / $2,885.12
| Facility | | $1,511.50 | $1,511.50 | $2,885.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.90 / $2,476.73 / $2,976.09
| Professional | | $1,958.90 | $2,476.73 | $2,976.09 |