- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $5,397.93
| Professional | | $2,608.16 | $2,608.16 | $5,397.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,952.63 / $2,952.63 / $2,952.63
| Facility | | $2,952.63 | $2,952.63 | $2,952.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,460.53 / $3,026.53 / $5,044.21
| Facility | | $2,460.53 | $3,026.53 | $5,044.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $5,044.21
| Professional | | $2,608.16 | $2,608.16 | $5,044.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,460.53 / $3,026.53 / $5,044.21
| Facility | | $2,460.53 | $3,026.53 | $5,044.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $5,044.21
| Professional | | $2,608.16 | $2,608.16 | $5,044.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,764.65 / $6,025.89
| Professional | | $2,608.16 | $2,764.65 | $6,025.89 |