- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $5,011.87
| Professional | | $1,819.70 | $1,819.70 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $4,365.16
| Facility | | $2,089.30 | $2,089.30 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,089.30
| Professional | | $1,819.70 | $1,819.70 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,905.46 / $5,128.61
| Facility | | $1,202.26 | $1,905.46 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,905.46 / $5,128.61
| Professional | | $1,202.26 | $1,905.46 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $4,365.16
| Facility | | $2,089.30 | $2,089.30 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,819.70 / $2,570.40
| Professional | | $79.43 | $1,819.70 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Professional | | $1,819.70 | $1,819.70 | $1,819.70 |