- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.62 / $2,570.62 / $4,501.84
| Professional | | $2,570.62 | $2,570.62 | $4,501.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,020.72 / $5,020.72 / $5,020.72
| Facility | | $5,020.72 | $5,020.72 | $5,020.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,020.72 / $5,020.72 / $5,020.72
| Professional | | $5,020.72 | $5,020.72 | $5,020.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,670.30 / $3,670.30 / $5,751.00
| Facility | | $3,670.30 | $3,670.30 | $5,751.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.32 / $2,679.32 / $3,670.30
| Professional | | $2,679.32 | $2,679.32 | $3,670.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,067.14 / $2,287.12 / $5,673.77
| Professional | | $2,067.14 | $2,287.12 | $5,673.77 |