- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.40 / $2,123.40 / $2,450.08
| Professional | | $2,123.40 | $2,123.40 | $2,450.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $3,148.57
| Facility | | $3,148.57 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $2,298.46 / $3,356.53
| Professional | | $2,298.46 | $2,298.46 | $3,356.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $3,148.57
| Facility | | $3,148.57 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $3,148.57 / $3,356.53
| Professional | | $2,298.46 | $3,148.57 | $3,356.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,447.21 / $3,104.50 / $5,030.34
| Professional | | $1,447.21 | $3,104.50 | $5,030.34 |