- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,084.16 / $2,084.16 / $2,404.80
| Professional | | $2,084.16 | $2,084.16 | $2,404.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,139.07 / $3,214.74 / $3,214.74
| Facility | | $3,139.07 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.88 / $2,732.53 / $3,311.18
| Professional | | $2,252.88 | $2,732.53 | $3,311.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,139.07 / $3,214.74 / $3,214.74
| Facility | | $3,139.07 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.88 / $3,214.74 / $3,311.18
| Professional | | $2,252.88 | $3,214.74 | $3,311.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.48 / $2,719.10 / $4,937.38
| Professional | | $1,420.48 | $2,719.10 | $4,937.38 |