- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,279.75 / $4,392.53 / $4,392.53
| Professional | | $3,279.75 | $4,392.53 | $4,392.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,621.85
| Facility | | $3,621.85 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,078.57 / $3,621.85 / $3,621.85
| Professional | | $3,078.57 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,621.85
| Facility | | $3,621.85 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,621.85
| Professional | | $3,621.85 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.80 / $3,499.47 / $3,908.30
| Professional | | $1,234.80 | $3,499.47 | $3,908.30 |