- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.16 / $3,301.56 / $3,301.56
| Professional | | $2,465.16 | $3,301.56 | $3,301.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $3,282.89
| Facility | | $3,282.89 | $3,282.89 | $3,282.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,790.46 / $3,282.89 / $3,381.38
| Professional | | $2,790.46 | $3,282.89 | $3,381.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $3,282.89
| Facility | | $3,282.89 | $3,282.89 | $3,282.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $3,381.38
| Professional | | $3,282.89 | $3,282.89 | $3,381.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.64 / $3,916.88 / $5,112.50
| Professional | | $1,906.64 | $3,916.88 | $5,112.50 |