- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,425.06 / $3,425.06 / $3,951.99
| Professional | | $3,425.06 | $3,425.06 | $3,951.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.36 / $4,072.36 / $5,158.66
| Facility | | $4,072.36 | $4,072.36 | $5,158.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $4,072.36 / $4,194.53
| Professional | | $2,972.82 | $4,072.36 | $4,194.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.36 / $4,072.36 / $5,158.66
| Facility | | $4,072.36 | $4,072.36 | $5,158.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $4,072.36 / $4,194.53
| Professional | | $2,972.82 | $4,072.36 | $4,194.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.37 / $4,157.64 / $8,113.95
| Professional | | $2,334.37 | $4,157.64 | $8,113.95 |