- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.26 / $1,949.26 / $2,436.58
| Professional | | $1,949.26 | $1,949.26 | $2,436.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,015.54 / $3,015.54 / $3,015.54
| Facility | | $3,015.54 | $3,015.54 | $3,015.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,961.58 / $4,961.58 / $4,961.58
| Professional | | $4,961.58 | $4,961.58 | $4,961.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,291.08 / $1,807.53 / $2,342.55
| Facility | | $1,291.08 | $1,807.53 | $2,342.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.85 / $2,350.29 / $3,092.00
| Professional | | $1,691.85 | $2,350.29 | $3,092.00 |