- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.02 / $2,574.02 / $4,507.80
| Professional | | $2,574.02 | $2,574.02 | $4,507.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,027.38 / $5,027.38 / $5,027.38
| Facility | | $5,027.38 | $5,027.38 | $5,027.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,027.38 / $5,027.38 / $5,027.38
| Professional | | $5,027.38 | $5,027.38 | $5,027.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $5,573.94
| Facility | | $3,294.10 | $3,294.10 | $5,573.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $2,404.69 / $3,294.10
| Professional | | $2,404.69 | $2,404.69 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.16 / $2,269.44 / $3,497.15
| Professional | | $2,051.16 | $2,269.44 | $3,497.15 |