- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,195.53 / $4,279.72 / $4,279.72
| Professional | | $3,195.53 | $4,279.72 | $4,279.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Facility | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,847.37 / $3,349.85 / $3,349.85
| Professional | | $2,847.37 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Facility | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Professional | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.88 / $2,522.88 / $3,807.80
| Professional | | $1,160.88 | $2,522.88 | $3,807.80 |