- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,255.92 / $3,255.92 / $3,756.83
| Professional | | $3,255.92 | $3,255.92 | $3,756.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,943.38 / $3,943.38 / $4,903.91
| Facility | | $3,943.38 | $3,943.38 | $4,903.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,878.67 / $3,631.44 / $4,061.68
| Professional | | $2,878.67 | $3,631.44 | $4,061.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,943.38 / $3,943.38 / $4,903.91
| Facility | | $3,943.38 | $3,943.38 | $4,903.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,878.67 / $3,943.38 / $4,061.68
| Professional | | $2,878.67 | $3,943.38 | $4,061.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,307.85 / $3,952.33 / $7,713.26
| Professional | | $2,307.85 | $3,952.33 | $7,713.26 |