- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,294.17 / $2,294.17 / $2,647.12
| Professional | | $2,294.17 | $2,294.17 | $2,647.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,455.38 / $3,798.08 / $3,798.08
| Facility | | $3,455.38 | $3,798.08 | $3,798.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $3,591.15 / $4,048.94
| Professional | | $2,772.60 | $3,591.15 | $4,048.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,455.38 / $3,798.08 / $3,798.08
| Facility | | $3,455.38 | $3,798.08 | $3,798.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $3,798.08 / $4,048.94
| Professional | | $2,772.60 | $3,798.08 | $4,048.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.60 / $3,533.03 / $5,434.90
| Professional | | $1,563.60 | $3,533.03 | $5,434.90 |