- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,263.32 / $3,263.32 / $3,765.37
| Professional | | $3,263.32 | $3,263.32 | $3,765.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,366.38 / $4,366.38 / $4,915.08
| Facility | | $4,366.38 | $4,366.38 | $4,915.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.46 / $4,366.38 / $4,497.37
| Professional | | $3,187.46 | $4,366.38 | $4,497.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,366.38 / $4,366.38 / $4,915.08
| Facility | | $4,366.38 | $4,366.38 | $4,915.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.46 / $4,366.38 / $4,497.37
| Professional | | $3,187.46 | $4,366.38 | $4,497.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,224.14 / $4,681.06 / $7,730.81
| Professional | | $2,224.14 | $4,681.06 | $7,730.81 |