- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,907.73 / $2,907.73 / $3,355.07
| Professional | | $2,907.73 | $2,907.73 | $3,355.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.78 / $3,813.78 / $4,379.50
| Facility | | $3,813.78 | $3,813.78 | $4,379.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $3,193.44 / $3,928.19
| Professional | | $2,784.06 | $3,193.44 | $3,928.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.78 / $3,813.78 / $4,379.50
| Facility | | $3,813.78 | $3,813.78 | $4,379.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $3,813.78 / $3,928.19
| Professional | | $2,784.06 | $3,813.78 | $3,928.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,061.05 / $3,529.68 / $6,888.41
| Professional | | $2,061.05 | $3,529.68 | $6,888.41 |