- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.27 / $2,334.27 / $2,693.39
| Professional | | $2,334.27 | $2,334.27 | $2,693.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,515.77 / $3,600.52 / $3,600.52
| Facility | | $3,515.77 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,523.38 / $3,060.44 / $3,708.54
| Professional | | $2,523.38 | $3,060.44 | $3,708.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,515.77 / $3,600.52 / $3,600.52
| Facility | | $3,515.77 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,523.38 / $3,600.52 / $3,708.54
| Professional | | $2,523.38 | $3,600.52 | $3,708.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,654.57 / $2,833.54 / $5,529.87
| Professional | | $1,654.57 | $2,833.54 | $5,529.87 |