- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,668.54 / $2,668.54 / $3,079.08
| Professional | | $2,668.54 | $2,668.54 | $3,079.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.37 / $3,745.37 / $4,019.22
| Facility | | $3,745.37 | $3,745.37 | $4,019.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $3,247.43
| Professional | | $2,734.12 | $2,734.12 | $3,247.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.37 / $3,745.37 / $4,019.22
| Facility | | $3,745.37 | $3,745.37 | $4,019.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $3,247.43
| Professional | | $2,734.12 | $2,734.12 | $3,247.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,818.76 / $3,919.69 / $6,321.76
| Professional | | $1,818.76 | $3,919.69 | $6,321.76 |