- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,736.08 / $2,736.08 / $2,736.08
| Professional | | $2,736.08 | $2,736.08 | $2,736.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $3,236.31
| Facility | | $2,290.69 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.08 / $2,290.69 / $3,993.75
| Professional | | $268.08 | $2,290.69 | $3,993.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.13 / $1,326.35 / $2,107.36
| Professional | | $752.13 | $1,326.35 | $2,107.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.70 / $329.01 / $2,193.42
| Facility | | $218.70 | $329.01 | $2,193.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.32 / $1,749.60 / $3,948.50
| Professional | | $1,385.32 | $1,749.60 | $3,948.50 |