- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $4,635.25
| Professional | | $2,698.05 | $2,698.05 | $4,635.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,054.40 / $3,054.40 / $3,054.40
| Facility | | $3,054.40 | $3,054.40 | $3,054.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.33 / $3,009.20 / $5,015.34
| Facility | | $2,545.33 | $3,009.20 | $5,015.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $5,015.34
| Professional | | $2,698.05 | $2,698.05 | $5,015.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.33 / $3,009.20 / $5,015.34
| Facility | | $2,545.33 | $3,009.20 | $5,015.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $5,015.34
| Professional | | $2,698.05 | $2,698.05 | $5,015.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,859.93 / $6,233.57
| Professional | | $2,698.05 | $2,859.93 | $6,233.57 |