- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.58 / $1,865.58 / $2,152.59
| Professional | | $1,865.58 | $1,865.58 | $2,152.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,297.39 / $3,297.39 / $3,297.39
| Facility | | $3,297.39 | $3,297.39 | $3,297.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.09 / $2,407.09 / $3,396.31
| Professional | | $2,407.09 | $2,407.09 | $3,396.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,297.39 / $3,297.39 / $3,297.39
| Facility | | $3,297.39 | $3,297.39 | $3,297.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.09 / $3,297.39 / $3,396.31
| Professional | | $2,407.09 | $3,297.39 | $3,396.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.50 / $2,873.00 / $4,419.56
| Professional | | $1,271.50 | $2,873.00 | $4,419.56 |