- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $5,198.92
| Professional | | $2,429.89 | $2,429.89 | $5,198.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,750.82 / $2,750.82 / $2,750.82
| Facility | | $2,750.82 | $2,750.82 | $2,750.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,292.35 / $2,763.95 / $4,606.59
| Facility | | $2,292.35 | $2,763.95 | $4,606.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $4,606.59
| Professional | | $2,429.89 | $2,429.89 | $4,606.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,292.35 / $2,763.95 / $4,606.59
| Facility | | $2,292.35 | $2,763.95 | $4,606.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $4,606.59
| Professional | | $2,429.89 | $2,429.89 | $4,606.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,575.67 / $5,614.02
| Professional | | $2,429.89 | $2,575.67 | $5,614.02 |