- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,630.78 / $5,495.41
| Professional | | $2,454.71 | $3,630.78 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,311.31 / $3,388.44
| Professional | | $2,818.38 | $3,311.31 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $2,511.89 / $3,801.89
| Facility | | $331.13 | $2,511.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,090.30 / $5,128.61
| Professional | | $1,905.46 | $3,090.30 | $5,128.61 |