- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,475.13 / $3,475.13 / $6,085.89
| Professional | | $3,475.13 | $3,475.13 | $6,085.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,787.36 / $6,787.36 / $6,787.36
| Facility | | $6,787.36 | $6,787.36 | $6,787.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,787.36 / $6,787.36 / $6,787.36
| Professional | | $6,787.36 | $6,787.36 | $6,787.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,423.18 / $4,423.18 / $7,290.91
| Facility | | $4,423.18 | $4,423.18 | $7,290.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,228.92 / $3,228.92 / $4,423.18
| Professional | | $3,228.92 | $3,228.92 | $4,423.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,931.04 / $3,242.96 / $4,997.30
| Professional | | $2,931.04 | $3,242.96 | $4,997.30 |