- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,896.54 / $2,896.54 / $3,342.16
| Professional | | $2,896.54 | $2,896.54 | $3,342.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,578.08 / $3,578.08 / $4,362.63
| Facility | | $3,578.08 | $3,578.08 | $4,362.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $2,612.00 / $3,010.08
| Professional | | $2,612.00 | $2,612.00 | $3,010.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,578.08 / $3,578.08 / $4,362.63
| Facility | | $3,578.08 | $3,578.08 | $4,362.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $2,612.00 / $3,010.08
| Professional | | $2,612.00 | $2,612.00 | $3,010.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.16 / $3,632.67 / $6,861.89
| Professional | | $1,974.16 | $3,632.67 | $6,861.89 |