- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,365.53 / $2,510.46 / $2,510.46
| Professional | | $2,365.53 | $2,510.46 | $2,510.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.46 / $3,657.46 / $3,657.46
| Facility | | $3,657.46 | $3,657.46 | $3,657.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,657.46 / $3,657.46 / $3,657.46
| Professional | | $3,657.46 | $3,657.46 | $3,657.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,398.56 / $1,398.56 / $3,657.46
| Facility | | $1,398.56 | $1,398.56 | $3,657.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,657.46 / $3,657.46 / $4,876.02
| Professional | | $3,657.46 | $3,657.46 | $4,876.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,361.41 / $3,822.77 / $4,218.24
| Professional | | $3,361.41 | $3,822.77 | $4,218.24 |