- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,960.14 / $2,960.14 / $3,415.55
| Professional | | $2,960.14 | $2,960.14 | $3,415.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,790.37 / $3,790.37 / $4,458.42
| Facility | | $3,790.37 | $3,790.37 | $4,458.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.97 / $3,777.86 / $3,904.08
| Professional | | $2,766.97 | $3,777.86 | $3,904.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,790.37 / $3,790.37 / $4,458.42
| Facility | | $3,790.37 | $3,790.37 | $4,458.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.97 / $3,790.37 / $3,904.08
| Professional | | $2,766.97 | $3,790.37 | $3,904.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.50 / $4,558.62 / $7,012.57
| Professional | | $2,017.50 | $4,558.62 | $7,012.57 |