- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.40 / $1,665.40 / $3,749.40
| Professional | | $1,665.40 | $1,665.40 | $3,749.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,233.70 / $3,233.70 / $3,233.70
| Professional | | $3,233.70 | $3,233.70 | $3,233.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $2,290.69
| Facility | | $2,290.69 | $2,290.69 | $2,290.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $3,236.31
| Professional | | $2,290.69 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $232.74 / $243.40 / $2,829.98
| Facility | | $232.74 | $243.40 | $2,829.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.32 / $1,857.12 / $3,095.20
| Professional | | $1,385.32 | $1,857.12 | $3,095.20 |