- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,746.30 / $3,746.30 / $4,322.66
| Professional | | $3,746.30 | $3,746.30 | $4,322.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,391.66 / $4,391.66 / $4,391.66
| Facility | | $4,391.66 | $4,391.66 | $4,391.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,732.91 / $3,732.91 / $4,523.41
| Professional | | $3,732.91 | $3,732.91 | $4,523.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,391.66 / $4,391.66 / $4,391.66
| Facility | | $4,391.66 | $4,391.66 | $4,391.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,732.91 / $4,391.66 / $4,523.41
| Professional | | $3,732.91 | $4,391.66 | $4,523.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,553.31 / $5,282.94 / $8,874.99
| Professional | | $2,553.31 | $5,282.94 | $8,874.99 |