- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,801.89 / $6,606.93
| Professional | | $3,467.37 | $3,801.89 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,467.37
| Professional | | $2,951.21 | $2,951.21 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $2,691.53 / $4,570.88
| Facility | | $269.15 | $2,691.53 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $4,897.79
| Professional | | $2,570.40 | $3,311.31 | $4,897.79 |