- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.58 / $2,027.13 / $2,134.58
| Professional | | $1,883.58 | $2,027.13 | $2,134.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,532.34 / $3,532.34 / $3,532.34
| Facility | | $3,532.34 | $3,532.34 | $3,532.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.61 / $2,578.61 / $3,532.34
| Professional | | $2,578.61 | $2,578.61 | $3,532.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,050.06 / $3,050.06 / $3,050.06
| Facility | | $3,050.06 | $3,050.06 | $3,050.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,061.64 / $2,446.48 / $3,805.54
| Professional | | $2,061.64 | $2,446.48 | $3,805.54 |