- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $6,251.56
| Professional | | $3,660.83 | $3,660.83 | $6,251.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,144.34 / $4,144.34 / $4,144.34
| Facility | | $4,144.34 | $4,144.34 | $4,144.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.62 / $4,036.21 / $6,727.02
| Facility | | $3,453.62 | $4,036.21 | $6,727.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.62 / $4,036.21 / $6,727.02
| Facility | | $3,453.62 | $4,036.21 | $6,727.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.59 / $3,660.83 / $3,919.73
| Professional | | $2,334.59 | $3,660.83 | $3,919.73 |