- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.41 / $1,862.41 / $1,862.41
| Professional | | $1,862.41 | $1,862.41 | $1,862.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $3,282.89
| Facility | | $3,282.89 | $3,282.89 | $3,282.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.28 / $3,282.89 / $6,731.25
| Professional | | $456.28 | $3,282.89 | $6,731.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,966.48 / $3,467.77 / $5,497.68
| Professional | | $1,966.48 | $3,467.77 | $5,497.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.41 / $2,859.96 / $4,138.68
| Professional | | $1,862.41 | $2,859.96 | $4,138.68 |