- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,169.85 / $2,169.85 / $2,503.67
| Professional | | $2,169.85 | $2,169.85 | $2,503.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,268.13 / $3,364.97 / $3,364.97
| Facility | | $3,268.13 | $3,364.97 | $3,364.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.42 / $2,533.46 / $3,587.23
| Professional | | $2,456.42 | $2,533.46 | $3,587.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,268.13 / $3,364.97 / $3,364.97
| Facility | | $3,268.13 | $3,364.97 | $3,364.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.42 / $3,364.97 / $3,587.23
| Professional | | $2,456.42 | $3,364.97 | $3,587.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.03 / $3,057.88 / $5,140.37
| Professional | | $1,538.03 | $3,057.88 | $5,140.37 |