- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,272.92 / $4,272.92 / $4,378.42
| Professional | | $4,272.92 | $4,272.92 | $4,378.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,483.93 / $4,483.93 / $4,483.93
| Facility | | $4,483.93 | $4,483.93 | $4,483.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,483.93 / $4,483.93 / $4,483.93
| Professional | | $4,483.93 | $4,483.93 | $4,483.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $918.76 / $4,700.21 / $7,187.97
| Facility | | $918.76 | $4,700.21 | $7,187.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,275.21 / $5,275.21 / $10,220.54
| Professional | | $5,275.21 | $5,275.21 | $10,220.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,275.21 / $5,275.21 / $5,275.21
| Professional | | $5,275.21 | $5,275.21 | $5,275.21 |