- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,966.77 / $2,966.77 / $5,195.60
| Professional | | $2,966.77 | $2,966.77 | $5,195.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,794.46 / $5,794.46 / $5,794.46
| Facility | | $5,794.46 | $5,794.46 | $5,794.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,794.46 / $5,794.46 / $5,794.46
| Professional | | $5,794.46 | $5,794.46 | $5,794.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $5,448.11
| Facility | | $2,780.72 | $2,780.72 | $5,448.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,029.93 / $2,780.72
| Professional | | $2,029.93 | $2,029.93 | $2,780.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.59 / $2,220.13 / $3,421.15
| Professional | | $2,006.59 | $2,220.13 | $3,421.15 |