- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,162.28 / $3,801.89
| Professional | | $3,090.30 | $3,162.28 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Professional | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,949.84 / $2,290.87
| Facility | | $1,862.09 | $1,949.84 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,235.94 / $3,801.89
| Professional | | $3,019.95 | $3,235.94 | $3,801.89 |