- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.91 / $872.91 / $872.91
| Professional | | $872.91 | $872.91 | $872.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,217.74 / $3,217.74 / $4,166.88
| Facility | | $3,217.74 | $3,217.74 | $4,166.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $3,187.33 / $3,217.74
| Professional | | $2,549.86 | $3,187.33 | $3,217.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,217.74 / $3,217.74 / $4,166.88
| Facility | | $3,217.74 | $3,217.74 | $4,166.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,219.13 / $2,662.96 / $3,217.74
| Professional | | $2,219.13 | $2,662.96 | $3,217.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $932.03 / $2,219.13
| Professional | | $932.03 | $932.03 | $2,219.13 |