- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,611.98 / $3,611.98 / $4,167.67
| Professional | | $3,611.98 | $3,611.98 | $4,167.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,938.58 / $4,938.58 / $5,440.20
| Facility | | $4,938.58 | $4,938.58 | $5,440.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,605.16 / $4,438.49 / $5,086.74
| Professional | | $3,605.16 | $4,438.49 | $5,086.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,938.58 / $4,938.58 / $5,440.20
| Facility | | $4,938.58 | $4,938.58 | $5,440.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,605.16 / $4,938.58 / $5,086.74
| Professional | | $3,605.16 | $4,938.58 | $5,086.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,461.77 / $5,356.83 / $8,556.77
| Professional | | $2,461.77 | $5,356.83 | $8,556.77 |