- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,668.42 / $2,668.42 / $4,673.12
| Professional | | $2,668.42 | $2,668.42 | $4,673.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,211.75 / $5,211.75 / $5,211.75
| Facility | | $5,211.75 | $5,211.75 | $5,211.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,211.75 / $5,211.75 / $5,211.75
| Professional | | $5,211.75 | $5,211.75 | $5,211.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.36 / $4,072.36 / $5,924.70
| Facility | | $4,072.36 | $4,072.36 | $5,924.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $2,972.82 / $4,072.36
| Professional | | $2,972.82 | $2,972.82 | $4,072.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.40 / $2,662.49 / $4,102.81
| Professional | | $2,406.40 | $2,662.49 | $4,102.81 |