- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,502.30 / $3,351.30 / $3,351.30
| Professional | | $2,502.30 | $3,351.30 | $3,351.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $3,655.97
| Facility | | $3,655.97 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,107.57 / $3,655.97 / $3,655.97
| Professional | | $3,107.57 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $3,655.97
| Facility | | $3,655.97 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $3,655.97
| Professional | | $3,655.97 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.71 / $2,228.81 / $4,021.56
| Professional | | $1,319.71 | $2,228.81 | $4,021.56 |