- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,540.46 / $2,686.01 / $2,879.00
| Professional | | $2,540.46 | $2,686.01 | $2,879.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,865.01 / $4,865.01 / $4,865.01
| Facility | | $4,865.01 | $4,865.01 | $4,865.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,551.46 / $3,551.46 / $4,865.01
| Professional | | $3,551.46 | $3,551.46 | $4,865.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,320.94 / $5,320.94 / $5,320.94
| Facility | | $5,320.94 | $5,320.94 | $5,320.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,780.63 / $3,299.68 / $4,712.66
| Professional | | $2,780.63 | $3,299.68 | $4,712.66 |