- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.23 / $2,272.23 / $2,272.23
| Professional | | $2,272.23 | $2,272.23 | $2,272.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,288.86 / $3,288.86 / $3,288.86
| Facility | | $3,288.86 | $3,288.86 | $3,288.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,799.01 / $3,799.01 / $3,799.01
| Professional | | $3,799.01 | $3,799.01 | $3,799.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,989.59 / $4,177.58 / $4,177.58
| Professional | | $3,989.59 | $4,177.58 | $4,177.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,989.59 / $3,989.59 / $3,989.59
| Professional | | $3,989.59 | $3,989.59 | $3,989.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,974.22 / $3,288.86 / $4,760.02
| Professional | | $2,974.22 | $3,288.86 | $4,760.02 |