- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,673.23 / $2,673.23 / $3,084.50
| Professional | | $2,673.23 | $2,673.23 | $3,084.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $3,728.42
| Facility | | $3,728.42 | $3,728.42 | $3,728.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $3,728.42 / $3,840.27
| Professional | | $2,721.75 | $3,728.42 | $3,840.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $3,728.42
| Facility | | $3,728.42 | $3,728.42 | $3,728.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $3,728.42 / $3,840.27
| Professional | | $2,721.75 | $3,728.42 | $3,840.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,821.95 / $3,495.76 / $6,326.55
| Professional | | $1,821.95 | $3,495.76 | $6,326.55 |