- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,461.58 / $3,461.58 / $4,326.97
| Professional | | $3,461.58 | $3,461.58 | $4,326.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,720.74 / $2,720.74 / $2,720.74
| Facility | | $2,720.74 | $2,720.74 | $2,720.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,639.00 / $6,016.53 / $6,016.53
| Professional | | $2,639.00 | $6,016.53 | $6,016.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $928.71 / $1,166.46 / $1,514.05
| Facility | | $928.71 | $1,166.46 | $1,514.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.94 / $1,514.05 / $2,940.56
| Professional | | $969.94 | $1,514.05 | $2,940.56 |