- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,268.48 / $4,377.43 / $4,377.43
| Professional | | $3,268.48 | $4,377.43 | $4,377.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $4,775.22
| Facility | | $4,775.22 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,058.94 / $4,775.22 / $4,775.22
| Professional | | $4,058.94 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $4,775.22
| Facility | | $4,775.22 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $4,775.22
| Professional | | $4,775.22 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,560.48 / $5,233.52 / $6,778.49
| Professional | | $2,560.48 | $5,233.52 | $6,778.49 |