- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,290.06 / $4,406.33 / $4,406.33
| Professional | | $3,290.06 | $4,406.33 | $4,406.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Facility | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,108.87 / $3,657.49 / $3,657.49
| Professional | | $3,108.87 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Facility | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Professional | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.36 / $3,465.84 / $3,682.46
| Professional | | $1,244.36 | $3,465.84 | $3,682.46 |