- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,651.66 / $3,651.66 / $3,651.66
| Professional | | $3,651.66 | $3,651.66 | $3,651.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $677.76 / $1,224.89 / $2,588.41
| Facility | | $677.76 | $1,224.89 | $2,588.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,531.73 / $3,739.65 / $3,739.65
| Professional | | $2,531.73 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $677.76 / $1,224.89 / $2,588.41
| Facility | | $677.76 | $1,224.89 | $2,588.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.91 / $563.91 / $3,739.65
| Professional | | $375.91 | $563.91 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,666.33 / $3,666.33 / $3,666.33
| Professional | | $3,666.33 | $3,666.33 | $3,666.33 |