- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.31 / $1,978.31 / $2,282.67
| Professional | | $1,978.31 | $1,978.31 | $2,282.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $3,001.57
| Facility | | $3,001.57 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $2,690.58 / $3,199.83
| Professional | | $2,191.15 | $2,690.58 | $3,199.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $3,001.57
| Facility | | $3,001.57 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $3,001.57 / $3,199.83
| Professional | | $2,191.15 | $3,001.57 | $3,199.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.73 / $2,975.87 / $4,681.93
| Professional | | $1,316.73 | $2,975.87 | $4,681.93 |