- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,768.95 / $3,768.95 / $3,989.95
| Professional | | $3,768.95 | $3,768.95 | $3,989.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,470.60 / $8,925.04 / $16,136.11
| Facility | | $2,470.60 | $8,925.04 | $16,136.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.95 / $2,470.60 / $3,366.19
| Professional | | $1,852.95 | $2,470.60 | $3,366.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,768.95 / $3,768.95 / $4,145.85
| Facility | | $3,768.95 | $3,768.95 | $4,145.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,768.95 / $3,768.95 / $3,768.95
| Professional | | $3,768.95 | $3,768.95 | $3,768.95 |