- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,009.35 / $3,247.71 / $3,456.28
| Professional | | $3,009.35 | $3,247.71 | $3,456.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,979.55 / $3,268.29 / $3,268.29
| Facility | | $2,979.55 | $3,268.29 | $3,268.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.55 / $3,268.29 / $3,268.29
| Professional | | $2,979.55 | $3,268.29 | $3,268.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,979.56 / $3,068.94 / $3,562.50
| Facility | | $2,979.56 | $3,068.94 | $3,562.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,106.23 / $3,232.54 / $4,216.35
| Professional | | $3,106.23 | $3,232.54 | $4,216.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $2,979.56
| Professional | | $2,979.56 | $2,979.56 | $2,979.56 |