- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,751.72 / $2,751.72 / $2,751.72
| Professional | | $2,751.72 | $2,751.72 | $2,751.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,714.26 / $3,714.26 / $3,714.26
| Facility | | $3,714.26 | $3,714.26 | $3,714.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,549.86 / $3,187.33
| Professional | | $2,549.86 | $2,549.86 | $3,187.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,714.26 / $3,714.26 / $3,714.26
| Facility | | $3,714.26 | $3,714.26 | $3,714.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,442.43 / $2,549.86 / $3,187.33
| Professional | | $1,442.43 | $2,549.86 | $3,187.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.48 / $1,331.48 / $3,106.78
| Professional | | $1,331.48 | $1,331.48 | $3,106.78 |