- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,119.53 / $3,119.53 / $3,948.88
| Professional | | $3,119.53 | $3,119.53 | $3,948.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,658.56 / $3,657.49 / $3,657.49
| Facility | | $2,658.56 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.92 / $3,657.49 / $3,657.49
| Professional | | $435.92 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,991.83 / $3,119.53 / $3,948.88
| Facility | | $2,991.83 | $3,119.53 | $3,948.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,590.80 / $4,590.80 / $4,590.80
| Professional | | $4,590.80 | $4,590.80 | $4,590.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,499.67 / $1,993.92 / $3,136.56
| Professional | | $1,499.67 | $1,993.92 | $3,136.56 |