- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,398.83 / $4,466.84
| Professional | | $2,187.76 | $2,398.83 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Professional | | $4,466.84 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $5,011.87
| Facility | | $3,019.95 | $3,019.95 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $4,168.69
| Professional | | $2,187.76 | $2,187.76 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,754.23 / $3,630.78
| Facility | | $1,584.89 | $2,754.23 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,089.30 / $3,235.94
| Professional | | $1,862.09 | $2,089.30 | $3,235.94 |