- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,020.31 / $3,020.31 / $3,484.97
| Professional | | $3,020.31 | $3,020.31 | $3,484.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $4,549.05
| Facility | | $4,052.23 | $4,052.23 | $4,549.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $3,476.61 / $4,173.80
| Professional | | $2,958.13 | $3,476.61 | $4,173.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $4,549.05
| Facility | | $4,052.23 | $4,052.23 | $4,549.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $4,052.23 / $4,173.80
| Professional | | $2,958.13 | $4,052.23 | $4,173.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.51 / $4,195.91 / $7,155.11
| Professional | | $2,058.51 | $4,195.91 | $7,155.11 |