- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,641.83 / $3,948.78 / $5,288.55
| Professional | | $3,641.83 | $3,948.78 | $5,288.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,303.28
| Facility | | $4,303.28 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,657.79 / $4,303.28 / $4,303.28
| Professional | | $3,657.79 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,303.28
| Facility | | $4,303.28 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,303.28
| Professional | | $4,303.28 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.15 / $4,190.72 / $4,705.60
| Professional | | $1,473.15 | $4,190.72 | $4,705.60 |