- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,038.47 / $2,038.47 / $2,352.08
| Professional | | $2,038.47 | $2,038.47 | $2,352.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.85 / $2,970.85 / $3,070.25
| Facility | | $2,970.85 | $2,970.85 | $3,070.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,550.85 / $3,167.07
| Professional | | $2,168.71 | $2,550.85 | $3,167.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.85 / $2,970.85 / $3,070.25
| Facility | | $2,970.85 | $2,970.85 | $3,070.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,970.85 / $3,167.07
| Professional | | $2,168.71 | $2,970.85 | $3,167.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.62 / $3,139.25 / $4,829.14
| Professional | | $1,847.62 | $3,139.25 | $4,829.14 |