- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,467.31 / $2,467.31 / $2,846.90
| Professional | | $2,467.31 | $2,467.31 | $2,846.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,670.30 / $3,670.30 / $3,716.14
| Facility | | $3,670.30 | $3,670.30 | $3,716.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.32 / $3,627.73 / $3,780.41
| Professional | | $2,679.32 | $3,627.73 | $3,780.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,670.30 / $3,670.30 / $3,716.14
| Facility | | $3,670.30 | $3,670.30 | $3,716.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.32 / $3,670.30 / $3,780.41
| Professional | | $2,679.32 | $3,670.30 | $3,780.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,277.52 / $3,799.66 / $5,845.05
| Professional | | $2,277.52 | $3,799.66 | $5,845.05 |