- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,800.75 / $2,800.75 / $4,379.35
| Professional | | $2,800.75 | $2,800.75 | $4,379.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,884.12 / $4,884.12 / $4,884.12
| Facility | | $4,884.12 | $4,884.12 | $4,884.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,884.12 / $4,884.12 / $4,884.12
| Professional | | $4,884.12 | $4,884.12 | $4,884.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $5,404.22
| Facility | | $2,756.64 | $2,756.64 | $5,404.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $4,379.64
| Professional | | $2,012.35 | $2,012.35 | $4,379.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.22 / $2,200.91 / $2,443.44
| Professional | | $1,989.22 | $2,200.91 | $2,443.44 |