- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,655.17 / $6,234.60 / $6,234.60
| Professional | | $4,655.17 | $6,234.60 | $6,234.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,704.40
| Facility | | $3,704.40 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,148.74 / $3,704.40 / $3,815.53
| Professional | | $3,148.74 | $3,704.40 | $3,815.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,704.40
| Facility | | $3,704.40 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,815.53
| Professional | | $3,704.40 | $3,704.40 | $3,815.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,455.07 / $3,971.68 / $6,137.67
| Professional | | $2,455.07 | $3,971.68 | $6,137.67 |