- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,509.55 / $3,509.55 / $4,049.48
| Professional | | $3,509.55 | $3,509.55 | $4,049.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,728.96 / $4,728.96 / $5,285.93
| Facility | | $4,728.96 | $4,728.96 | $5,285.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $4,728.96 / $4,870.83
| Professional | | $3,452.14 | $4,728.96 | $4,870.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,728.96 / $4,728.96 / $5,285.93
| Facility | | $4,728.96 | $4,728.96 | $5,285.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $4,728.96 / $4,870.83
| Professional | | $3,452.14 | $4,728.96 | $4,870.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,391.94 / $4,593.64 / $8,314.12
| Professional | | $2,391.94 | $4,593.64 | $8,314.12 |